Provider Demographics
NPI:1699793406
Name:KENNEALLY, CYNTHIA Z (MD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:Z
Last Name:KENNEALLY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8096
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-275-2020
Mailing Address - Fax:314-275-8719
Practice Address - Street 1:1040 N MASON RD
Practice Address - Street 2:SUITE 219
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6399
Practice Address - Country:US
Practice Address - Phone:314-275-2020
Practice Address - Fax:314-275-8719
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-08-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR2D39207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202473419Medicaid
MO202473419Medicaid
028010103Medicare PIN
IL$$$$$$$$$Medicaid
180016291Medicare PIN