Provider Demographics
NPI:1104841857
Name:KENNEDY, CARLOS C (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:C
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 1:213 MAMA SANDY ST
Mailing Address - Street 2:
Mailing Address - City:PITI
Mailing Address - State:GU
Mailing Address - Zip Code:96915-5532
Mailing Address - Country:US
Mailing Address - Phone:671-344-9315
Mailing Address - Fax:
Practice Address - Street 1:2819 N PARHAM RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4425
Practice Address - Country:US
Practice Address - Phone:804-288-9466
Practice Address - Fax:804-288-9326
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01083917A207X00000X
VA0101236797207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty