Healthcare Provider Details

I. General information

NPI: 1992252944
Provider Name (Legal Business Name): JAGDISH DESAI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAGDISH P DESAI

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 W 69TH ST
CHICAGO IL
60636-3316
US

IV. Provider business mailing address

1608 W 69TH ST
CHICAGO IL
60636-3316
US

V. Phone/Fax

Practice location:
  • Phone: 773-778-3420
  • Fax:
Mailing address:
  • Phone: 773-778-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-033681
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: