Healthcare Provider Details

I. General information

NPI: 1114000767
Provider Name (Legal Business Name): AASHISH KIRAN DESAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 190
CANTON GA
30115-8018
US

IV. Provider business mailing address

900 TOWNE LAKE PKWY STE 400
WOODSTOCK GA
30189-1604
US

V. Phone/Fax

Practice location:
  • Phone: 470-639-6250
  • Fax: 770-345-0712
Mailing address:
  • Phone: 404-921-0638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number052165
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberTRN8397
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number52165
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: