Provider Demographics
NPI:1063470029
Name:DESAI, MRUDULA (MD)
Entity Type:Individual
Prefix:
First Name:MRUDULA
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1718
Mailing Address - Country:US
Mailing Address - Phone:708-749-4660
Mailing Address - Fax:708-749-4665
Practice Address - Street 1:2137 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1718
Practice Address - Country:US
Practice Address - Phone:708-749-4660
Practice Address - Fax:708-749-4665
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207004Medicare ID - Type Unspecified
ILD14605Medicare UPIN