Provider Demographics
NPI:1376927186
Name:KENNEDY, PAUL (LDO)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5810
Mailing Address - Country:US
Mailing Address - Phone:912-352-2953
Mailing Address - Fax:912-352-7946
Practice Address - Street 1:2 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5810
Practice Address - Country:US
Practice Address - Phone:912-352-2953
Practice Address - Fax:912-352-7946
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001911156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician