Provider Demographics
NPI:1104024256
Name:DEPONTE, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DEPONTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 SUNSET DR
Mailing Address - Street 2:STE 3
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7906
Mailing Address - Country:US
Mailing Address - Phone:423-979-5610
Mailing Address - Fax:423-926-1823
Practice Address - Street 1:935 VIRGINIA AVE NW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1818
Practice Address - Country:US
Practice Address - Phone:276-679-2729
Practice Address - Fax:276-679-0578
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA351772085R0202X
TNMD355102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007200781Medicaid
KY64794456Medicaid
VA007200781Medicaid