Healthcare Provider Details

I. General information

NPI: 1427084839
Provider Name (Legal Business Name): KISHORE K DESAGANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E VALENCIA MESA DR
FULLERTON CA
92835-3809
US

IV. Provider business mailing address

4199 CAMPUS DR STE 550
IRVINE CA
92612-4694
US

V. Phone/Fax

Practice location:
  • Phone: 949-689-0288
  • Fax: 949-509-6599
Mailing address:
  • Phone: 949-689-0288
  • Fax: 949-509-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA99666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: