Provider Demographics
NPI:1396273173
Name:KENNEDY, THOMAS LYNN JR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LYNN
Last Name:KENNEDY
Suffix:JR
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 1:620 W GROVE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4425
Mailing Address - Country:US
Mailing Address - Phone:870-875-5580
Mailing Address - Fax:870-875-5584
Practice Address - Street 1:620 W GROVE ST STE 201
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4425
Practice Address - Country:US
Practice Address - Phone:870-875-5580
Practice Address - Fax:870-875-5584
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
ARE-15513208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty