Healthcare Provider Details

I. General information

NPI: 1639398845
Provider Name (Legal Business Name): MARSHAL TERRANCE KENNEDY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: M TERRY KENNEDY DPM

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 11/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 SE POWELL VALLEY RD
GRESHAM OR
97080-1475
US

IV. Provider business mailing address

2775 SE POWELL VALLEY RD
GRESHAM OR
97080-1475
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-7789
  • Fax: 503-667-2032
Mailing address:
  • Phone: 503-667-7789
  • Fax: 503-667-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDP00139
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: