Provider Demographics
NPI:1508897810
Name:KENNEDY, COLLEEN I (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:I
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 RIDGE RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-4206
Mailing Address - Country:US
Mailing Address - Phone:214-775-1356
Mailing Address - Fax:214-613-2231
Practice Address - Street 1:1309 RIDGE RD
Practice Address - Street 2:SUITE 109
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4206
Practice Address - Country:US
Practice Address - Phone:214-775-1356
Practice Address - Fax:214-613-2231
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.15581R208600000X
TXM7325208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5765Medicare PIN
H92240Medicare UPIN