Healthcare Provider Details

I. General information

NPI: 1881699080
Provider Name (Legal Business Name): MANISH I DESAI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5909 W 35TH ST
CICERO IL
60804-4163
US

IV. Provider business mailing address

5909 W 35TH ST
CICERO IL
60804-4163
US

V. Phone/Fax

Practice location:
  • Phone: 708-652-2040
  • Fax: 708-652-0058
Mailing address:
  • Phone: 708-652-2040
  • Fax: 708-652-0058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036105725
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: