Provider Demographics
NPI:1730461690
Name:KENNEDY, JAMES (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 SAN PABLO STREET
Mailing Address - Street 2:SUITE 514
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5324
Mailing Address - Country:US
Mailing Address - Phone:323-442-7909
Mailing Address - Fax:323-442-6020
Practice Address - Street 1:1510 SAN PABLO STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5324
Practice Address - Country:US
Practice Address - Phone:323-442-7909
Practice Address - Fax:323-442-6020
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118410208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFO087ZMedicare PIN