Provider Demographics
NPI:1679578033
Name:KENDALL, KENYON S (DO)
Entity type:Individual
Prefix:DR
First Name:KENYON
Middle Name:S
Last Name:KENDALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E BELTLINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6049
Mailing Address - Country:US
Mailing Address - Phone:616-949-2600
Mailing Address - Fax:616-365-2076
Practice Address - Street 1:750 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6049
Practice Address - Country:US
Practice Address - Phone:616-949-2600
Practice Address - Fax:616-365-2076
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007594207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180007179OtherMEDICARE RR
MI180D148331OtherBCBS
MI1934460Medicaid
MI180007179OtherMEDICARE RR
MI0D17001Medicare PIN
MI180D148331OtherBCBS