Provider Demographics
NPI:1356371884
Name:KASENDORF, ROGER ASHLEY (DO)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ASHLEY
Last Name:KASENDORF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9834 GENESEE AVE STE 427
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1264
Mailing Address - Country:US
Mailing Address - Phone:516-336-4362
Mailing Address - Fax:858-244-0152
Practice Address - Street 1:9834 GENESEE AVE STE 221
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1215
Practice Address - Country:US
Practice Address - Phone:858-558-1275
Practice Address - Fax:858-244-0152
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2021-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239449-1208100000X
CA20A129282081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02940027Medicaid
NYA300020386Medicare PIN