Provider Demographics
NPI:1003150715
Name:DESHPANDE, VRUSHAK (MD)
Entity Type:Individual
Prefix:
First Name:VRUSHAK
Middle Name:
Last Name:DESHPANDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:904-398-7205
Mailing Address - Fax:
Practice Address - Street 1:3635 CLYDE MORRIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2349
Practice Address - Country:US
Practice Address - Phone:386-788-1242
Practice Address - Fax:386-756-8802
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME138988207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102986300Medicaid