Basic Information
| Provider Information | |||||||||
| NPI: | 1386646529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESAI | ||||||||
| FirstName: | SHREYAS | ||||||||
| MiddleName: | ARVIND | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2640 HAMSTROM RD | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463683832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197629523 | ||||||||
| FaxNumber: | 2197633120 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 HAMSTROM RD | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463683832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197629523 | ||||||||
| FaxNumber: | 2197633120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 01027933A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207R00000X | 01027933A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100157480A | 05 | IN | MEDICAID | 200201230 | 05 | IN | MEDICAID |