Healthcare Provider Details

I. General information

NPI: 1447233408
Provider Name (Legal Business Name): DONALD E KENNEDY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 TAMIAMI TRL
PORT CHARLOTTE FL
33952-3922
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 2
ST AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 941-624-2704
  • Fax: 941-627-6066
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS0004552
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: