Provider Demographics
NPI:1235229378
Name:DESAI, ANGELINE CN (MD)
Entity Type:Individual
Prefix:
First Name:ANGELINE
Middle Name:CN
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 1:7956 PLANTATION LAKES DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3011
Mailing Address - Country:US
Mailing Address - Phone:772-489-5852
Mailing Address - Fax:
Practice Address - Street 1:7200 HWY. 441 NORTH
Practice Address - Street 2:ECKERD YOUTH DEVELOPMENT CENTER
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972
Practice Address - Country:US
Practice Address - Phone:863-763-2174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME292242084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D67271Medicare UPIN
79296Medicare ID - Type Unspecified