Provider Demographics
NPI:1245242510
Name:DESAI, GAUTAM J (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:J
Last Name:DESAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:842 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1503
Mailing Address - Country:US
Mailing Address - Phone:732-222-0180
Mailing Address - Fax:732-222-3990
Practice Address - Street 1:842 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1503
Practice Address - Country:US
Practice Address - Phone:732-222-0180
Practice Address - Fax:732-222-3990
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA07111300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG84563Medicare UPIN
NJ041745Medicare ID - Type Unspecified