Provider Demographics
NPI:1093809568
Name:KENNEDY, DANIEL J (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
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 1:1637 WESTSHORE ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2973
Mailing Address - Country:US
Mailing Address - Phone:530-756-3009
Mailing Address - Fax:
Practice Address - Street 1:1637 WESTSHORE ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-2973
Practice Address - Country:US
Practice Address - Phone:530-756-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47015207R00000X
CAG59571207RC0200X, 208M00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G595710Medicaid
E81278Medicare UPIN
CA00G595710Medicaid
CA00G595710Medicaid