Provider Demographics
NPI:1487766937
Name:KENNEDY, BOBBY JOE (DO)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:JOE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
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 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:6811 AUSTIN CENTER BLVD
Practice Address - Street 2:#300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3146
Practice Address - Country:US
Practice Address - Phone:512-346-8888
Practice Address - Fax:512-344-0312
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6115207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097806603Medicaid
TX097806604Medicaid
TXCZ49OtherBCBS
TXCZ49Medicaid
TX097806603Medicaid
TXTXB136606Medicare PIN
TXP00997929Medicare PIN
TXCZ49OtherBCBS
A67252Medicare UPIN