Provider Demographics
NPI:1255599130
Name:DESIMONE, DENNIS CHARLES (DO)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:CHARLES
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:2202 N JOHN B DENNIS HWY STE 204
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5904
Practice Address - Country:US
Practice Address - Phone:423-245-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17849207VG0400X, 207VX0201X
TN5369207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA000381OtherSTATE LICENSE
LA2369351Medicaid
NJ9448769OtherCIGNA
NJ8424735OtherAETNA
NJ60091909OtherHORIZON NJ HEALTH
NJ01474196OtherAMERIGROUP