Basic Information
| Provider Information | |||||||||
| NPI: | 1699777847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESJARDINS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8593010655 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8593010655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 38980 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 90008962 | 01 | KY | MEDICAID DME | OTHER | 64088594 | 05 | KY | MEDICAID | CB8861 | 01 | KY | RAILROAD MEDICARE | OTHER | P00156471 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000333833 | 01 | KY | ANTHEM | OTHER | 0428850004 | 01 | KY | MEDICARE DME | OTHER |