Provider Demographics
NPI:1992713192
Name:KENNELLY, PAUL (DPM)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:KENNELLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 HOOPER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8130
Mailing Address - Country:US
Mailing Address - Phone:732-255-8805
Mailing Address - Fax:732-255-8091
Practice Address - Street 1:1749 HOOPER AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8130
Practice Address - Country:US
Practice Address - Phone:732-255-8805
Practice Address - Fax:732-255-8091
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD 002445213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7541503Medicaid
NJU41869Medicare UPIN
NJ007054Medicare ID - Type Unspecified