Basic Information
| Provider Information | |||||||||
| NPI: | 1861464596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESHPANDE | ||||||||
| FirstName: | KRISHNARAJ | ||||||||
| MiddleName: | GOPAL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722235665 | ||||||||
| FaxNumber: | 7722235646 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SE HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722235628 | ||||||||
| FaxNumber: | 7722235652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 05/28/2014 | ||||||||
| 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 | 207R00000X | OS11305 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2515842 | 01 | NC | UNITED HEALTHCARE | OTHER | 5900619 | 05 | NC | MEDICAID | 805410 | 01 | NC | PARTNERS | OTHER | 14TP5 | 01 | FL | FLORIDA BLUE | OTHER | 2335816 | 01 | NC | MEDICARE PTAN - GROUP | OTHER | 2402381D | 01 | NC | MEDICARE PTAN - INDIVIDUAL | OTHER | E0721 | 01 | NC | MEDCOST | OTHER | 138VK | 01 | NC | BCBS OF NC | OTHER | 7613628 | 01 | NC | AETNA | OTHER | 010555700 | 05 | FL | MEDICAID |