Provider Demographics
NPI:1366673568
Name:WAH, DESMOND JY (MD)
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:JY
Last Name:WAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DESMOND
Other - Middle Name:
Other - Last Name:WAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47006-0236
Mailing Address - Country:US
Mailing Address - Phone:812-933-5441
Mailing Address - Fax:
Practice Address - Street 1:321 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-8909
Practice Address - Country:US
Practice Address - Phone:812-934-6624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073560A208M00000X, 208M00000X
CAA143206208M00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01473875Medicaid
INPENDINGMedicaid
OH0066854Medicaid
ORR182654Medicare PIN
AZZ186887Medicare PIN
CO360544YLFEMedicare PIN
OH0066854Medicaid