MEDICARE: DR. SHRUTI DESAI OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG003421	PA
2	152W00000X	Optometrist	OPC5873	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OEG003421	OTHER	PA	LICENSE

General Provider Information

NPI Number	:	1588140636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHRUTI DESAI OD

Provider Business Mailing Address
First Line	:	817 NW 56TH TER STE B
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32605-6401
Country	:	US
Telephone Number	:	352-331-7771
Fax Number	:

Provider Business Practice Location Address
First Line	:	817 NW 56TH TER STE B
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32605-6401
Country	:	US
Telephone Number	:	352-331-7771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2018
Last Update Date	:	12/04/2020

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