Provider Demographics
NPI:1922060599
Name:KENNEDY, SCOTT A (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
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 1:1073 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3129
Mailing Address - Country:US
Mailing Address - Phone:814-333-6606
Mailing Address - Fax:
Practice Address - Street 1:122 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1761
Practice Address - Country:US
Practice Address - Phone:814-827-7931
Practice Address - Fax:814-827-0746
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000659152WV0400X, 152WP0200X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA418623Medicare PIN
PAT30300Medicare UPIN
PA0191050001Medicare NSC