Healthcare Provider Details

I. General information

NPI: 1922140615
Provider Name (Legal Business Name): AMOL SUDHAKAR DESHPANDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 PROSPECT DR
TRINITY TX
75862-6202
US

IV. Provider business mailing address

103 HAWTHORN
LUFKIN TX
75904-5361
US

V. Phone/Fax

Practice location:
  • Phone: 936-594-7375
  • Fax: 936-594-3797
Mailing address:
  • Phone: 936-634-2128
  • Fax: 936-594-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK5089
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: