Provider Demographics
NPI:1326066713
Name:KENNEDY, DENISE R (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:R
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 COTTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45335-1518
Mailing Address - Country:US
Mailing Address - Phone:937-675-2870
Mailing Address - Fax:937-675-2873
Practice Address - Street 1:4790 COTTONVILLE RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:OH
Practice Address - Zip Code:45335-1518
Practice Address - Country:US
Practice Address - Phone:937-675-2870
Practice Address - Fax:937-675-2873
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122127207Q00000X
OH35.084408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2622773Medicaid
I48732Medicare UPIN
OH4176973Medicare PIN
OHH122350Medicare PIN
OH2622773Medicaid