Healthcare Provider Details

I. General information

NPI: 1992768113
Provider Name (Legal Business Name): CRAIG KENNEDY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E WADE WATTS AVE
MCALESTER OK
74501-5652
US

IV. Provider business mailing address

1400 E WADE WATTS AVE
MCALESTER OK
74501-5652
US

V. Phone/Fax

Practice location:
  • Phone: 918-429-1400
  • Fax: 918-429-1403
Mailing address:
  • Phone: 918-429-1400
  • Fax: 918-429-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2160
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: