Provider Demographics
NPI:1942576111
Name:KENNEDY, CHARLES DERENSBOUGH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DERENSBOUGH
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:229 SYCAMORE GROVE ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-7342
Mailing Address - Country:US
Mailing Address - Phone:805-217-6724
Mailing Address - Fax:805-217-6724
Practice Address - Street 1:229 SYCAMORE GROVE ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-7342
Practice Address - Country:US
Practice Address - Phone:805-217-6724
Practice Address - Fax:805-217-6724
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-31
Last Update Date:2012-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG066894207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine