Provider Demographics
NPI:1164616074
Name:DESHMUKH, VINOD (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:VINOD
Middle Name:
Last Name:DESHMUKH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HEALTH PARK BLVD
Mailing Address - Street 2:SUITE 5010
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3707
Mailing Address - Country:US
Mailing Address - Phone:904-808-0406
Mailing Address - Fax:904-808-0504
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 5010
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3707
Practice Address - Country:US
Practice Address - Phone:904-808-0406
Practice Address - Fax:904-808-0504
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32674174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD52607Medicare UPIN
FL15480XMedicare PIN