Healthcare Provider Details

I. General information

NPI: 1801984604
Provider Name (Legal Business Name): AVINASH S DESHPANDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 N STATE ROUTE 2
NEW MARTINSVILLE WV
26155-2203
US

IV. Provider business mailing address

253 N STATE ROUTE 2
NEW MARTINSVILLE WV
26155-2203
US

V. Phone/Fax

Practice location:
  • Phone: 304-455-1019
  • Fax: 304-455-0141
Mailing address:
  • Phone: 304-455-1019
  • Fax: 304-455-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19828
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: