Provider Demographics
NPI:1386646529
Name:DESAI, SHREYAS ARVIND (MD)
Entity Type:Individual
Prefix:DR
First Name:SHREYAS
Middle Name:ARVIND
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 1:2640 HAMSTROM RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3832
Mailing Address - Country:US
Mailing Address - Phone:219-762-9523
Mailing Address - Fax:219-763-3120
Practice Address - Street 1:2640 HAMSTROM RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3832
Practice Address - Country:US
Practice Address - Phone:219-762-9523
Practice Address - Fax:219-763-3120
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027933A207QA0505X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100157480AMedicaid
IN200201230Medicaid
IN235780Medicare PIN
IN100157480AMedicaid
INC25010Medicare UPIN