Provider Demographics
NPI:1447233408
Name:KENNEDY, DONALD E (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2460 OLD MOULTRIE RD
Mailing Address - Street 2:STE 2
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:2450 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-3922
Practice Address - Country:US
Practice Address - Phone:941-624-2704
Practice Address - Fax:941-627-6066
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS0004552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82515OtherFL BC
FLD60658Medicare UPIN
FL82515XMedicare PIN
FL82515VMedicare PIN