Provider Demographics
NPI:1699777847
Name:DESJARDINS, MATTHEW TODD (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TODD
Last Name:DESJARDINS
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 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:560 S LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3405
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-301-0655
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38980207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90008962OtherMEDICAID DME
KY64088594Medicaid
KYCB8861OtherRAILROAD MEDICARE
KYP00156471OtherRAILROAD MEDICARE
KY000000333833OtherANTHEM
KY0428850004OtherMEDICARE DME
KY64088594Medicaid
KY0389218Medicare PIN