Healthcare Provider Details

I. General information

NPI: 1821054172
Provider Name (Legal Business Name): MEENAKSHI M DESAI MD FACS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MEENAKSHI M DESAI MD FACS

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 BROADWAY
MT VERNON IL
62864-0020
US

IV. Provider business mailing address

PO BOX 986
MT VERNON IL
62864-2340
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-3200
  • Fax: 618-244-3254
Mailing address:
  • Phone: 618-244-3200
  • Fax: 618-244-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036053115
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: