Provider Demographics
NPI:1376642249
Name:DESMARAIS, PAUL HERMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:HERMAN
Last Name:DESMARAIS
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 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-204-6440
Mailing Address - Fax:574-239-1435
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-204-6440
Practice Address - Fax:574-239-1435
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052725A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200296480Medicaid
INM400071222Medicare PIN
IN200296480Medicaid