Provider Demographics
NPI:1629364328
Name:KENNEDY, MONA (MD)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7517
Mailing Address - Country:US
Mailing Address - Phone:833-334-6393
Mailing Address - Fax:415-354-3430
Practice Address - Street 1:1153 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7517
Practice Address - Country:US
Practice Address - Phone:833-334-6393
Practice Address - Fax:415-354-3430
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2767002083B0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine