Healthcare Provider Details

I. General information

NPI: 1063774776
Provider Name (Legal Business Name): VISHAL DESAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2012
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 CHAPEL AVE W
CHERRY HILL NJ
08002-2048
US

IV. Provider business mailing address

2201 CHAPEL AVE W
CHERRY HILL NJ
08002-2048
US

V. Phone/Fax

Practice location:
  • Phone: 856-488-6500
  • Fax: 856-488-6507
Mailing address:
  • Phone: 856-488-6500
  • Fax: 856-488-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA10344700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT202281
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD460148
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: