Provider Demographics
NPI:1841234895
Name:DESA, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:DESA
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 1:1037 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2913
Mailing Address - Country:US
Mailing Address - Phone:914-734-8800
Mailing Address - Fax:914-734-8745
Practice Address - Street 1:6 HENRY ST
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-3058
Practice Address - Country:US
Practice Address - Phone:845-831-0400
Practice Address - Fax:845-831-0793
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247544207Q00000X
NYX001263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02250580Medicaid
NYH38322Medicare UPIN
A400047081Medicare PIN