Healthcare Provider Details

I. General information

NPI: 1699777847
Provider Name (Legal Business Name): MATTHEW TODD DESJARDINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

IV. Provider business mailing address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2663
  • Fax: 859-301-0655
Mailing address:
  • Phone: 859-301-2663
  • Fax: 859-301-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number38980
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: