Provider Demographics
NPI:1568664258
Name:KENNEDY, JOHN DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DANIEL
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 1:1650 COUNTY SERVICES PKWY SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4010
Mailing Address - Country:US
Mailing Address - Phone:770-514-2300
Mailing Address - Fax:
Practice Address - Street 1:1650 COUNTY SERVICES PKWY SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4010
Practice Address - Country:US
Practice Address - Phone:770-514-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022573208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
GAD45832Medicare UPIN