Healthcare Provider Details

I. General information

NPI: 1134172414
Provider Name (Legal Business Name): MUKESH DESAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 LAGRANGE ST
WEST LAFAYETTE BRA IN
47906-1153
US

IV. Provider business mailing address

441 LAGRANGE ST
WEST LAFAYETTE BRA IN
47906-1153
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-7128
  • Fax:
Mailing address:
  • Phone: 765-463-7128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01032177A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: