Provider Demographics
NPI:1205064334
Name:KENNEDY, CALEB JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:JOSEPH
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 1:18503 PINES BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1405
Mailing Address - Country:US
Mailing Address - Phone:954-430-8330
Mailing Address - Fax:954-430-3638
Practice Address - Street 1:18503 PINES BLVD STE 205
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1405
Practice Address - Country:US
Practice Address - Phone:954-430-8330
Practice Address - Fax:954-430-3638
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4146152W00000X
FL004146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist