1417047663 NPI number — MR. GAUTAM D DESAI MD

Table of content: MR. GAUTAM D DESAI MD (NPI 1417047663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417047663 NPI number — MR. GAUTAM D DESAI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESAI
Provider First Name:
GAUTAM
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417047663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 S INDEPENDENCE BLVD
Provider Second Line Business Mailing Address:
SUITE #3
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-471-6977
Provider Business Mailing Address Fax Number:
757-471-5300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 S INDEPENDENCE BLVD
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-471-6977
Provider Business Practice Location Address Fax Number:
757-471-5300
Provider Enumeration Date:
10/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101045379 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080100260 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005628881 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 332419 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".