Provider Demographics
NPI:1588603922
Name:DEASON, KORY V (MD)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:V
Last Name:DEASON
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 1:321 E HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1629
Mailing Address - Country:US
Mailing Address - Phone:517-543-1050
Mailing Address - Fax:517-543-0875
Practice Address - Street 1:321 E HARRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1629
Practice Address - Country:US
Practice Address - Phone:517-543-1050
Practice Address - Fax:517-543-0875
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044811207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101558254Medicaid
MI3900122OtherPHYSICIANS HEALTH PLAN
MIKD044811OtherBCBS
MI3970122OtherPHP FAMILY CARE
MIP105859OtherBLUE CARE NETWORK
MIKD044811OtherBCBS
MIB36008018Medicare ID - Type Unspecified