Healthcare Provider Details

I. General information

NPI: 1386646529
Provider Name (Legal Business Name): SHREYAS ARVIND DESAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 HAMSTROM RD
PORTAGE IN
46368-3832
US

IV. Provider business mailing address

2640 HAMSTROM RD
PORTAGE IN
46368-3832
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-9523
  • Fax: 219-763-3120
Mailing address:
  • Phone: 219-762-9523
  • Fax: 219-763-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number01027933A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01027933A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: