1790430189 NPI number — KRISHNA H DESAI

Table of content: KRISHNA H DESAI (NPI 1790430189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790430189 NPI number — KRISHNA H DESAI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESAI
Provider First Name:
KRISHNA
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1790430189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
172 BLACK MOUNTAIN CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94536-6530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-736-9890
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7584 E STATE ROUTE 69
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314-2278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-736-9890
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2022

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: 122300000X , with the licence number:  016.0134081 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D011685 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: $$$$$$$$$ , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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