Provider Demographics
NPI:1437710985
Name:KENNEDY, GERARD
Entity Type:Individual
Prefix:MR
First Name:GERARD
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3919
Mailing Address - Country:US
Mailing Address - Phone:516-707-9859
Mailing Address - Fax:
Practice Address - Street 1:71 W 21ST ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-3919
Practice Address - Country:US
Practice Address - Phone:516-707-9859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6060171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty