Healthcare Provider Details

I. General information

NPI: 1013301316
Provider Name (Legal Business Name): SHYAM JAYANT DESHPANDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 07/04/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

V. Phone/Fax

Practice location:
  • Phone: 267-426-2958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number274306
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60950335
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD478006
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: