Healthcare Provider Details

I. General information

NPI: 1801183173
Provider Name (Legal Business Name): DANA EDWARD KENNEDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 LOMITA BLVD
TORRANCE CA
90505-5002
US

IV. Provider business mailing address

26924 GRAYSLAKE RD
RANCHO PALOS VERDES CA
90275-2107
US

V. Phone/Fax

Practice location:
  • Phone: 310-784-4997
  • Fax:
Mailing address:
  • Phone: 805-689-6260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA128688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: