Provider Demographics
NPI:1912095787
Name:KENNEDY, JOHN M (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1990 INDUSTRIAL BLVD.
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:985-868-9300
Mailing Address - Fax:985-851-0053
Practice Address - Street 1:1990 INDUSTRIAL BLVD.
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-868-9300
Practice Address - Fax:985-851-0053
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA025329207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1575780Medicaid
LA4J6507627Medicare PIN
LAI31928Medicare UPIN
LA1575780Medicaid