Provider Demographics
NPI:1235120288
Name:KENNEDY, DAVID M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
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 1:1450 S CANFIELD NILES RD
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515
Mailing Address - Country:US
Mailing Address - Phone:330-792-7485
Mailing Address - Fax:330-792-7842
Practice Address - Street 1:1450 S CANFIELD NILES RD
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515
Practice Address - Country:US
Practice Address - Phone:330-792-7495
Practice Address - Fax:330-792-7842
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060712207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0857970Medicaid
OHF23449Medicare UPIN
OHKE0713289Medicare ID - Type Unspecified