Provider Demographics
NPI:1437250073
Name:KENNEDY, DAVID LAWRENCE (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 OLD COUNTY ROAD 15
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6210
Mailing Address - Country:US
Mailing Address - Phone:763-545-8850
Mailing Address - Fax:763-544-1257
Practice Address - Street 1:10600 OLD COUNTY ROAD 15
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6210
Practice Address - Country:US
Practice Address - Phone:763-545-8850
Practice Address - Fax:763-544-1257
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLF1587000152W00000X
MNLD1587000152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN417R6KEOtherBCBS
MN2202707OtherMEDICA
MN963723100Medicaid
MN977521011194OtherPREFERRED ONE
MNT39282Medicare UPIN
MN963723100Medicaid