Provider Demographics
NPI:1992733224
Name:KENNEDY, DAMON MARK (DO)
Entity type:Individual
Prefix:DR
First Name:DAMON
Middle Name:MARK
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 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-934-3628
Practice Address - Street 1:4802 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-8413
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-934-3628
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO478922080P0202X, 2086S0120X
CODR.0047892208600000X, 208G00000X
WY10460A208G00000X
TXL2368208G00000X
ARE-18514208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68856750Medicaid
NE10025839700Medicaid
CO68856750Medicaid
TX861257Medicare PIN
TX861258Medicare PIN