Healthcare Provider Details

I. General information

NPI: 1689809535
Provider Name (Legal Business Name): KETAN DESAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 N CUTHBERT ST
COLQUITT GA
39837-3518
US

IV. Provider business mailing address

209 N CUTHBERT ST
COLQUITT GA
39837-3518
US

V. Phone/Fax

Practice location:
  • Phone: 229-281-6096
  • Fax: 229-281-6097
Mailing address:
  • Phone: 229-281-6096
  • Fax: 229-281-6097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number105102
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: