Provider Demographics
NPI:1356332555
Name:KENNEDY, CRAIG ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALLEN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1530 BIXBY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNDS
Mailing Address - State:OK
Mailing Address - Zip Code:74047-5335
Mailing Address - Country:US
Mailing Address - Phone:918-366-9152
Mailing Address - Fax:918-366-1170
Practice Address - Street 1:1530 BIXBY RD
Practice Address - Street 2:
Practice Address - City:MOUNDS
Practice Address - State:OK
Practice Address - Zip Code:74047-5335
Practice Address - Country:US
Practice Address - Phone:918-366-9152
Practice Address - Fax:918-366-1170
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14981207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK930085465OtherRAILROAD MEDICARE
OK100790580DMedicaid
OK100790580DMedicaid