MEDICARE: DR. BOBBY JOE KENNEDY DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	E6115	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	CZ49	OTHER	TX	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487766937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BOBBY JOE KENNEDY DO

Provider Business Mailing Address
First Line	:	PO BOX 26726
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78755-0726
Country	:	US
Telephone Number	:	512-407-8686
Fax Number	:	512-406-6216

Provider Business Practice Location Address
First Line	:	6811 AUSTIN CENTER BLVD
Second Line	:	#300
City	:	AUSTIN
State	:	TX
Zip	:	78731-3146
Country	:	US
Telephone Number	:	512-346-8888
Fax Number	:	512-344-0312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	03/02/2012

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