Provider Demographics
NPI:1629069307
Name:KENNEDY, WARREN LEIGH (OD)
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:LEIGH
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 1:1401 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1367
Mailing Address - Country:US
Mailing Address - Phone:209-527-6640
Mailing Address - Fax:209-527-5489
Practice Address - Street 1:1401 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1367
Practice Address - Country:US
Practice Address - Phone:209-527-6640
Practice Address - Fax:209-527-5489
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6390TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12100OtherMEDICAL EYE SERVICES
T10308Medicare UPIN
CA12100OtherMEDICAL EYE SERVICES