Provider Demographics
NPI:1164406278
Name:DESELMS, KENDALL P (DO, DC)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:P
Last Name:DESELMS
Suffix:
Gender:M
Credentials:DO, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E EVERGREEN ST
Mailing Address - Street 2:PO BOX 557
Mailing Address - City:CAMERON
Mailing Address - State:MO
Mailing Address - Zip Code:64429-2400
Mailing Address - Country:US
Mailing Address - Phone:816-632-2101
Mailing Address - Fax:816-649-3383
Practice Address - Street 1:221 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-1722
Practice Address - Country:US
Practice Address - Phone:816-632-8407
Practice Address - Fax:816-632-2943
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005457111N00000X
MO107636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO785D378OtherMEDICARE PART B
MOP00191306OtherMEDICARE RAILROAD
MO249751009Medicaid
MO249751009Medicaid