Provider Demographics
NPI:1104882810
Name:KENNEDY, PETER SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:SAMUEL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81172
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91118-1172
Mailing Address - Country:US
Mailing Address - Phone:213-484-6474
Mailing Address - Fax:213-484-8470
Practice Address - Street 1:201 S ALVARADO ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2320
Practice Address - Country:US
Practice Address - Phone:213-484-6474
Practice Address - Fax:213-484-8470
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38037207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00380370Medicaid
CA00380370Medicaid
CAWC38037TMedicare PIN