Provider Demographics
NPI:1376654624
Name:DESAI, BAKUL (MD)
Entity Type:Individual
Prefix:
First Name:BAKUL
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PAVONIA AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2929
Mailing Address - Country:US
Mailing Address - Phone:201-216-3060
Mailing Address - Fax:201-499-0253
Practice Address - Street 1:600 PAVONIA AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2929
Practice Address - Country:US
Practice Address - Phone:201-216-3060
Practice Address - Fax:201-499-0253
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03746000207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3705307Medicaid
NJ466346Medicare ID - Type Unspecified
NJ3705307Medicaid