Healthcare Provider Details

I. General information

NPI: 1164616074
Provider Name (Legal Business Name): VINOD DESHMUKH M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD SUITE 5010
ST AUGUSTINE FL
32086-3707
US

IV. Provider business mailing address

300 HEALTH PARK BLVD SUITE 5010
ST AUGUSTINE FL
32086-3707
US

V. Phone/Fax

Practice location:
  • Phone: 904-808-0406
  • Fax: 904-808-0504
Mailing address:
  • Phone: 904-808-0406
  • Fax: 904-808-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME32674
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: