Provider Demographics
NPI:1881754000
Name:KENNEDY, MARY C (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:DEHECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1850 MILFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2079
Mailing Address - Country:US
Mailing Address - Phone:770-736-6185
Mailing Address - Fax:
Practice Address - Street 1:1550 SCENIC HWY N
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2130
Practice Address - Country:US
Practice Address - Phone:770-979-9456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
41ZCDBTMedicare ID - Type Unspecified