Basic Information
| Provider Information | |||||||||
| NPI: | 1366673568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAH | ||||||||
| FirstName: | DESMOND | ||||||||
| MiddleName: | JY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAH | ||||||||
| OtherFirstName: | DESMOND | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 236 | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470060236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129335441 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4455 EDISON LAKES PKWY | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742316800 | ||||||||
| FaxNumber: | 3076380394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | DR.0054052 | CO | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | A143206 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 01073560A | IN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 01473875 | 05 | CO | MEDICAID | PENDING | 05 | IN | MEDICAID | 0066854 | 05 | OH | MEDICAID |