Healthcare Provider Details

I. General information

NPI: 1093916785
Provider Name (Legal Business Name): CHARLES D. KENNARD MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 INTERSTATE 20 W SUITE G14
ARLINGTON TX
76017
US

IV. Provider business mailing address

811 INTERSTATE 20 W SUITE G14
ARLINGTON TX
76017-5870
US

V. Phone/Fax

Practice location:
  • Phone: 817-460-4444
  • Fax: 817-460-8844
Mailing address:
  • Phone: 817-460-4444
  • Fax: 817-460-8844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License NumberMDK0086
License Number StateTX

VIII. Authorized Official

Name: DR. CHARLES D KENNARD
Title or Position: PRESIDENT
Credential: MD
Phone: 817-460-4444