Basic Information
Provider Information | |||||||||
NPI: | 1760445423 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESAI | ||||||||
FirstName: | SHAILESH | ||||||||
MiddleName: | DHIRUBHAI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 324 | ||||||||
Address2: |   | ||||||||
City: | SIOUX CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 511020324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122795830 | ||||||||
FaxNumber: | 7122795883 | ||||||||
Practice Location | |||||||||
Address1: | 240 NORTH RERICK AVE | ||||||||
Address2: |   | ||||||||
City: | PRIMGHAR | ||||||||
State: | IA | ||||||||
PostalCode: | 51245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7129572310 | ||||||||
FaxNumber: | 7129570504 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2006 | ||||||||
LastUpdateDate: | 10/17/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31556 | IA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2145151 | 05 | IA |   | MEDICAID | 3145151 | 05 | IA |   | MEDICAID | 4145151 | 05 | IA |   | MEDICAID | 5145151 | 05 | IA |   | MEDICAID | 22768 | 01 | IA | SIOUX VALLEY HEALTH PLAN | OTHER | 48073 | 01 | IA | WELLMARK BCBS IA | OTHER |