1598745911 NPI number — DR. MARK ALFRED DESJARDINS MD

Table of content: DR. MARK ALFRED DESJARDINS MD (NPI 1598745911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598745911 NPI number — DR. MARK ALFRED DESJARDINS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESJARDINS
Provider First Name:
MARK
Provider Middle Name:
ALFRED
Provider Name Prefix Text:
DR.
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:
1598745911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
UNIT 33109 BOX 4713R
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09180-0947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-536-1555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL AMBULATORY CARE CENTER
Provider Second Line Business Practice Location Address:
ROUTE 12 BLDG 449 ATTN PROFESSIONAL AFFAIRS
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06349-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-694-2377
Provider Business Practice Location Address Fax Number:
860-694-2590
Provider Enumeration Date:
01/20/2006

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:  9300 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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