Healthcare Provider Details

I. General information

NPI: 1487612420
Provider Name (Legal Business Name): SUBODH C DESAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2137 OAK PARK AVE
BERWYN IL
60402-1718
US

IV. Provider business mailing address

2137 OAK PARK AVE
BERWYN IL
60402-1718
US

V. Phone/Fax

Practice location:
  • Phone: 708-749-4660
  • Fax: 708-749-4665
Mailing address:
  • Phone: 708-749-4660
  • Fax: 708-749-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: