Basic Information
Provider Information | |||||||||
NPI: | 1871709824 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESHPANDE | ||||||||
FirstName: | CHETAN | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4425 PAULSEN ST | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314053662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123556615 | ||||||||
FaxNumber: | 9123510645 | ||||||||
Practice Location | |||||||||
Address1: | 4425 PAULSEN ST | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314053662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123556615 | ||||||||
FaxNumber: | 9123510645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2007 | ||||||||
LastUpdateDate: | 02/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 063314 | GA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0801X | 063314 | GA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
ID | Type | State | Issuer | Description | 146082906C | 05 | GA |   | MEDICAID | 559738 | 01 | GA | WELLCARE | OTHER | GA1084 | 05 | SC |   | MEDICAID | P00869905 | 01 | GA | RR MEDICARE | OTHER |