Individual
DR. KENNETH P DEPERSIO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
100 DOCTORS DR STE F, DOUGLAS, GA 31533-2211
(912) 383-6575
(912) 383-6476
Mailing address
100 DOCTORS DR STE I, DOUGLAS, GA 31533-2211
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
053329
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
053329
MEDICAL LICENSE
GA
01
—
205778734002
TRICARE
—
01
—
341176
WELLCARE OF GEORGIA
GA
05
—
904817618C
—
GA
05
—
904817618D
—
GA
01
—
956500
BCBS
GA
01
—
GRP7930
MEDICARE GROUP # EFFECTIVE 02/01/2008
GA
01
—
P00127268
RAILROAD MEDICARE
GA
Enumeration date
02/27/2006
Last updated
03/07/2023
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