1619021003 NPI number — DR. JAYANT B DESAI MD

Table of content: DR. JAYANT B DESAI MD (NPI 1619021003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619021003 NPI number — DR. JAYANT B DESAI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESAI
Provider First Name:
JAYANT
Provider Middle Name:
B
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:
1619021003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
716 MAIDEN CHOICE LN
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-5943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-788-8264
Provider Business Mailing Address Fax Number:
410-788-8254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
716 MAIDEN CHOICE LN
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228-5943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-788-8264
Provider Business Practice Location Address Fax Number:
410-788-8254
Provider Enumeration Date:
01/22/2007

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: 208600000X , with the licence number:  D0022417 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: T5260001 . This is a "CARE FIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 020001226 . This is a "RR MC #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 130551400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41272703 . This is a "CARE FIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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