Basic Information
Provider Information | |||||||||
NPI: | 1679551386 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESAI | ||||||||
FirstName: | RAJEN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3709 N CAMPBELL AVE | ||||||||
Address2: | STE 201 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857191563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208383138 | ||||||||
FaxNumber: | 5208382260 | ||||||||
Practice Location | |||||||||
Address1: | 4729 E CAMP LOWELL DR | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857121256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5203214800 | ||||||||
FaxNumber: | 5208382400 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2006 | ||||||||
LastUpdateDate: | 05/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 31618 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 795982 | 05 | AZ |   | MEDICAID |