Provider Demographics
NPI:1639398845
Name:KENNEDY, MARSHAL TERRANCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARSHAL
Middle Name:TERRANCE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:M
Other - Middle Name:TERRY
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2775 SE POWELL VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-1475
Mailing Address - Country:US
Mailing Address - Phone:503-667-7789
Mailing Address - Fax:503-667-2032
Practice Address - Street 1:2775 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1475
Practice Address - Country:US
Practice Address - Phone:503-667-7789
Practice Address - Fax:503-667-2032
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00139213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR283523Medicaid
ORR0000SGBFVMedicare ID - Type Unspecified
OR283523Medicaid