Provider Demographics
NPI:1134120512
Name:KENNEDY, RICHARD P (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:P
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:P.O. BOX 5299
Mailing Address - Street 2:MS: 1313-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1603 COOPER POINT RD NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8325
Practice Address - Country:US
Practice Address - Phone:253-572-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034315207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
C17809Medicare UPIN
AB20358Medicare ID - Type Unspecified