Provider Demographics
NPI:1700832219
Name:PASSERI, KENNETH JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:PASSERI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2483 PADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-2428
Mailing Address - Country:US
Mailing Address - Phone:925-829-4641
Mailing Address - Fax:650-342-0525
Practice Address - Street 1:2483 PADDOCK DR
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-2428
Practice Address - Country:US
Practice Address - Phone:925-829-4641
Practice Address - Fax:925-905-8971
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3347213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E33470Medicaid
CAT11644Medicare UPIN
000E33471Medicare ID - Type Unspecified