Healthcare Provider Details

I. General information

NPI: 1508394255
Provider Name (Legal Business Name): KEYUR SURESH DESAI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

PO BOX 744785
ATLANTA GA
30374-4785
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-5000
  • Fax:
Mailing address:
  • Phone: 202-476-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD210001516
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: