Provider Demographics
NPI:1952345563
Name:KENNEL, DAVID ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ROBERT
Last Name:KENNEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 100TH ST. SW
Mailing Address - Street 2:#31
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-0000
Mailing Address - Country:US
Mailing Address - Phone:253-584-3023
Mailing Address - Fax:253-582-1222
Practice Address - Street 1:5920 100TH ST. SW
Practice Address - Street 2:#31
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-0000
Practice Address - Country:US
Practice Address - Phone:253-584-3023
Practice Address - Fax:253-582-1222
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1106046Medicaid
WAG8850854Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
WA1106046Medicaid