Provider Demographics
NPI:1801986575
Name:KENNY, RICHARD S (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:S
Last Name:KENNY
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 1:225 106TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5713
Mailing Address - Country:US
Mailing Address - Phone:425-454-2028
Mailing Address - Fax:425-451-1497
Practice Address - Street 1:225 106TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5713
Practice Address - Country:US
Practice Address - Phone:425-454-2028
Practice Address - Fax:425-451-1497
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1492 TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2008696Medicaid
WAG000106947Medicare ID - Type Unspecified
WA2008696Medicaid
WATO2014Medicare UPIN