Provider Demographics
NPI:1417059239
Name:DESANDIES, KENNETH ANDRE (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ANDRE
Last Name:DESANDIES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6192 OXON HILL RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745
Mailing Address - Country:US
Mailing Address - Phone:301-567-0978
Mailing Address - Fax:301-567-3155
Practice Address - Street 1:6192 OXON HILL RD
Practice Address - Street 2:SUITE 303
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745
Practice Address - Country:US
Practice Address - Phone:301-567-0978
Practice Address - Fax:301-567-3155
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22793207V00000X
VA029522207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6287930Medicaid
VA6287930Medicaid
VA166170Medicare ID - Type Unspecified
C88113Medicare UPIN