1265830673 NPI number — PRAJAKTA DESHPANDE, MD

Table of content: (NPI 1265830673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265830673 NPI number — PRAJAKTA DESHPANDE, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAJAKTA DESHPANDE, MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1265830673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8051
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98908-0051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-252-9150
Provider Business Mailing Address Fax Number:
714-252-9157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6800 LINCOLN AVE
Provider Second Line Business Practice Location Address:
SUITE 203 B
Provider Business Practice Location Address City Name:
BUENA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90620-4162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-252-9150
Provider Business Practice Location Address Fax Number:
714-252-9157
Provider Enumeration Date:
12/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DESHPANDE
Authorized Official First Name:
PRAJAKTA
Authorized Official Middle Name:
ABHIJIT
Authorized Official Title or Position:
MD, DIRECTOR
Authorized Official Telephone Number:
714-252-9150

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD133444 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS1201X , with the licence number: MD133444 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 024822 . This is a "BL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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