Provider Demographics
NPI:1053429159
Name:KENNEDY, DIANA L (MD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4205 MCAULEY BLVD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8347
Mailing Address - Country:US
Mailing Address - Phone:405-751-6111
Mailing Address - Fax:405-751-0479
Practice Address - Street 1:4205 MCAULEY BLVD
Practice Address - Street 2:SUITE 420
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8347
Practice Address - Country:US
Practice Address - Phone:405-751-6111
Practice Address - Fax:405-751-0479
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2013-04-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK13883207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD34889Medicare UPIN