Healthcare Provider Details

I. General information

NPI: 1104024256
Provider Name (Legal Business Name): KATHLEEN DEPONTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 VIRGINIA AVE NW
NORTON VA
24273-1818
US

IV. Provider business mailing address

1301 SUNSET DR STE 3
JOHNSON CITY TN
37604-7906
US

V. Phone/Fax

Practice location:
  • Phone: 276-679-2729
  • Fax: 276-679-0578
Mailing address:
  • Phone: 423-979-5610
  • Fax: 423-926-1823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35177
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD35510
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: