Provider Demographics
NPI:1154478543
Name:DESAI, SHOBHANA RAJENDRA (MD)
Entity Type:Individual
Prefix:
First Name:SHOBHANA
Middle Name:RAJENDRA
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 1:6530 BASSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098
Mailing Address - Country:US
Mailing Address - Phone:248-828-1086
Mailing Address - Fax:
Practice Address - Street 1:5790 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2991
Practice Address - Country:US
Practice Address - Phone:248-625-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043191207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE26727Medicare UPIN