Provider Demographics
NPI:1154396307
Name:KENNEDY, CATHERINE KAREN (OD)
Entity type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:KAREN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:11645 ANGUS RD BLDG A STE 5
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4100
Practice Address - Country:US
Practice Address - Phone:512-345-5641
Practice Address - Fax:512-345-0863
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3809TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0148105-01Medicaid
TX0148105-01Medicaid