Healthcare Provider Details

I. General information

NPI: 1366519084
Provider Name (Legal Business Name): ABHILASH DESAI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N ALLUMBAUGH ST STE 101
BOISE ID
83704-9219
US

IV. Provider business mailing address

413 N ALLUMBAUGH ST STE 101
BOISE ID
83704-9219
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-1125
  • Fax: 208-323-9604
Mailing address:
  • Phone: 617-922-4957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-12079
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: