Provider Demographics
NPI:1780604462
Name:DISESSA, THOMAS GERALD (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GERALD
Last Name:DISESSA
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 1:3945 PEPPERTREE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1398
Mailing Address - Country:US
Mailing Address - Phone:859-219-8632
Mailing Address - Fax:
Practice Address - Street 1:3945 PEPPERTREE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1398
Practice Address - Country:US
Practice Address - Phone:859-219-8632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY380902080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64920507Medicaid
A98007Medicare UPIN
KY64920507Medicaid