Provider Demographics
NPI:1982626594
Name:DESOTO, KERI RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:KERI
Middle Name:RAE
Last Name:DESOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1058 FAIR ST S
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305
Mailing Address - Country:US
Mailing Address - Phone:928-443-7777
Mailing Address - Fax:888-972-8306
Practice Address - Street 1:1058 FAIR ST
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305
Practice Address - Country:US
Practice Address - Phone:928-443-7777
Practice Address - Fax:888-972-8306
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ31505207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H49525Medicare UPIN
AZ79790Medicare ID - Type Unspecified