Healthcare Provider Details

I. General information

NPI: 1558500801
Provider Name (Legal Business Name): KENNEDY LEGEL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4228 N CENTRAL EXPY STE 210
DALLAS TX
75206-6556
US

IV. Provider business mailing address

4228 N CENTRAL EXPY STE 210
DALLAS TX
75206-6556
US

V. Phone/Fax

Practice location:
  • Phone: 214-366-4600
  • Fax: 214-366-4603
Mailing address:
  • Phone: 214-366-4600
  • Fax: 214-366-4603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP03358
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1911
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: