Provider Demographics
NPI:1407957509
Name:KENNEDY, FRANK (MD)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:
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 1:2435 RIDGEGATE ROW
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-0919
Mailing Address - Country:US
Mailing Address - Phone:858-565-0104
Mailing Address - Fax:858-656-0194
Practice Address - Street 1:2435 RIDGEGATE ROW
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0919
Practice Address - Country:US
Practice Address - Phone:858-565-0104
Practice Address - Fax:858-656-0194
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57613208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHG57613Medicare ID - Type Unspecified
CAFO8300Medicare UPIN