Basic Information
Provider Information | |||||||||
NPI: | 1851681134 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEEPTHI S SAXENA MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVANT-GARDE MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4225 LINCOLNSHIRE DR STE B | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | IL | ||||||||
PostalCode: | 628642157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182422317 | ||||||||
FaxNumber: | 6182429710 | ||||||||
Practice Location | |||||||||
Address1: | 9355 WARRICK WELLNESS TRL | ||||||||
Address2: |   | ||||||||
City: | NEWBURGH | ||||||||
State: | IN | ||||||||
PostalCode: | 476300015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124769983 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2011 | ||||||||
LastUpdateDate: | 07/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CULL | ||||||||
AuthorizedOfficialFirstName: | DEEPTHI | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8477670137 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 07/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 12455 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.