Provider Demographics
NPI:1083933535
Name:KENNEDY, GANNON DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:GANNON
Middle Name:DANIEL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ARGUELLO ST STE 100
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1567
Mailing Address - Country:US
Mailing Address - Phone:650-995-1285
Mailing Address - Fax:650-995-1208
Practice Address - Street 1:500 ARGUELLO ST STE 100
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1567
Practice Address - Country:US
Practice Address - Phone:650-995-1285
Practice Address - Fax:650-995-1208
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117899207X00000X, 207XX0005X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program