Provider Demographics
NPI:1568447563
Name:DESROSIER, KENNETH F (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:F
Last Name:DESROSIER
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 1:8527 VILLAGE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5513
Mailing Address - Country:US
Mailing Address - Phone:210-590-9596
Mailing Address - Fax:210-590-6227
Practice Address - Street 1:8527 VILLAGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5513
Practice Address - Country:US
Practice Address - Phone:210-590-9596
Practice Address - Fax:210-590-6227
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52995207RR0500X
TXM7946207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613177Medicare PIN