Provider Demographics
NPI:1154556603
Name:DESART, KENNETH MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:DESART
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-724-1950
Mailing Address - Fax:
Practice Address - Street 1:2575 ELMS CENTER RD STE 200
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9875
Practice Address - Country:US
Practice Address - Phone:843-724-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC838352086S0129X, 208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC838357Medicaid
FL022646300Medicaid