Provider Demographics
NPI:1093916785
Name:CHARLES D. KENNARD MD PA
Entity Type:Organization
Organization Name:CHARLES D. KENNARD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENNARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-460-4444
Mailing Address - Street 1:811 INTERSTATE 20 W SUITE G14
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5870
Mailing Address - Country:US
Mailing Address - Phone:817-460-4444
Mailing Address - Fax:817-460-8844
Practice Address - Street 1:811 INTERSTATE 20 W SUITE G14
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017
Practice Address - Country:US
Practice Address - Phone:817-460-4444
Practice Address - Fax:817-460-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDK0086170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty