Basic Information
| Provider Information | |||||||||
| NPI: | 1326012113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESAI | ||||||||
| FirstName: | MAULIN | ||||||||
| MiddleName: | MAHESH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5000 COX RD | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230609263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049685700 | ||||||||
| FaxNumber: | 8042177991 | ||||||||
| Practice Location | |||||||||
| Address1: | 3432 HOLLAND RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234524846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574681855 | ||||||||
| FaxNumber: | 7574684441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 0101232624 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 0101232624 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010094500 | 05 | VA | MEDICAID |