1760576094 NPI number — PRAJAKTA DESHPANDE MD

Table of content: PRAJAKTA DESHPANDE MD (NPI 1760576094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760576094 NPI number — PRAJAKTA DESHPANDE MD

Organization/Personal Information

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

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:
1760576094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 DISTEL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ALTOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94022-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-573-5261
Provider Business Mailing Address Fax Number:
707-573-5414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 W. LA VETA AVE.
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-4229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-547-5404
Provider Business Practice Location Address Fax Number:
714-547-0935
Provider Enumeration Date:
10/03/2006

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:  MD00042638 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: C133444 , 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: 0224597 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8386849 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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