Provider Demographics
NPI:1275526386
Name:KENNEDY, JOHN SARGENT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SARGENT
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 1:2665 N DECATUR RD
Mailing Address - Street 2:SUITE 730
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6149
Mailing Address - Country:US
Mailing Address - Phone:404-508-4320
Mailing Address - Fax:404-508-4112
Practice Address - Street 1:2665 N DECATUR RD
Practice Address - Street 2:SUITE 730
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6149
Practice Address - Country:US
Practice Address - Phone:404-508-4320
Practice Address - Fax:404-508-4112
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA25193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00280167CMedicaid
GAD45831Medicare UPIN
GA00280167CMedicaid