Healthcare Provider Details

I. General information

NPI: 1104867050
Provider Name (Legal Business Name): SANDRA P DESAI DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12734 KENWOOD LN SUITE 44
FORT MYERS FL
33907-5666
US

IV. Provider business mailing address

12734 KENWOOD LN SUITE 44
FORT MYERS FL
33907-5666
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-2454
  • Fax: 239-936-1974
Mailing address:
  • Phone: 239-936-2454
  • Fax: 239-936-1974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2882
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2833
License Number StateFL

VIII. Authorized Official

Name: LAURA TOADVINE
Title or Position: OFFICE MANAGER
Credential:
Phone: 239-936-2454