=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386640415
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVI DESHMUKH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 HILL BLVD STE 106-107
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-599-3690
-----------------------------------------------------
Fax | 817-599-6633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 HILL BLVD STE 106-107
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-1481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-599-3690
-----------------------------------------------------
Fax | 817-599-6633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | H1067
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------