Provider Demographics
NPI:1134282932
Name:DESAI, AMISH J (MD)
Entity Type:Individual
Prefix:
First Name:AMISH
Middle Name:J
Last Name:DESAI
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:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:501 N GRAHAM ST., SUITE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-413-7162
Practice Address - Fax:503-413-4711
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045340207RC0000X, 207RI0011X
ORMD169913207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500683050Medicaid
WA8431264Medicaid
WA1134282932Medicaid
WA0199511OtherLABOR AND INDUSTRIES
OR500683050Medicaid
ORR180699Medicare PIN
WA0199511OtherLABOR AND INDUSTRIES