Provider Demographics
NPI:1437125812
Name:DEPERSIO, KENNETH P (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:P
Last Name:DEPERSIO
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 1:100 DOCTORS DR STE I
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 DOCTORS DR STE F
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2211
Practice Address - Country:US
Practice Address - Phone:912-383-6575
Practice Address - Fax:912-383-6476
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053329207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA341176OtherWELLCARE OF GEORGIA
GA904817618CMedicaid
GA904817618DMedicaid
GA956500OtherBCBS
205778734002OtherTRICARE
GAGRP7930OtherMEDICARE GROUP # EFFECTIVE 02/01/2008
GAP00127268OtherRAILROAD MEDICARE
GA053329OtherMEDICAL LICENSE
GA053329OtherGA LICENSE
GA053329OtherGA LICENSE
GAAD9685453OtherDEA
GA956500OtherBCBS