Provider Demographics
NPI:1194177972
Name:DESAI, VIVEK
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 FRANKLIN AVE
Mailing Address - Street 2:STE 250
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-1306
Mailing Address - Country:US
Mailing Address - Phone:844-777-0910
Mailing Address - Fax:201-560-0712
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1047
Practice Address - Country:US
Practice Address - Phone:617-665-1566
Practice Address - Fax:617-665-2699
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2330363A00000X
MAPA6015363A00000X
363A00000X
VT055.0031539363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant