Provider Demographics
NPI:1093050007
Name:DESAI, ANISH (MD)
Entity Type:Individual
Prefix:
First Name:ANISH
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 STE B
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8054
Mailing Address - Country:US
Mailing Address - Phone:631-978-7633
Mailing Address - Fax:631-686-2578
Practice Address - Street 1:1500 ROUTE 112 STE B
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8054
Practice Address - Country:US
Practice Address - Phone:631-978-7633
Practice Address - Fax:631-621-4119
Is Sole Proprietor?:No
Enumeration Date:2012-12-02
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY280824207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04494735Medicaid