Provider Demographics
NPI:1255227567
Name:MARTIN, KENEDI (OD)
Entity type:Individual
Prefix:DR
First Name:KENEDI
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 STATLER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1126
Mailing Address - Country:US
Mailing Address - Phone:636-627-1090
Mailing Address - Fax:
Practice Address - Street 1:5605 STATLER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-1126
Practice Address - Country:US
Practice Address - Phone:636-627-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025022272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist