Provider Demographics
NPI:1609974120
Name:KENNEDY, ROBERT E (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11824 BELLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111
Mailing Address - Country:US
Mailing Address - Phone:734-699-1010
Mailing Address - Fax:
Practice Address - Street 1:11824 BELLEVILLE RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111
Practice Address - Country:US
Practice Address - Phone:734-699-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944729248Medicaid
MI944729248Medicaid
MI0N32990Medicare ID - Type Unspecified