Healthcare Provider Details

I. General information

NPI: 1144216318
Provider Name (Legal Business Name): SUVAS GHELABHAI DESAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 MARIE LANGDON DR
MANCHESTER KY
40962-6329
US

IV. Provider business mailing address

56 MARIE LANGDON DR
MANCHESTER KY
40962-6329
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-5104
  • Fax: 606-598-1688
Mailing address:
  • Phone: 606-598-5104
  • Fax: 606-598-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number16723
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: