Provider Demographics
NPI:1417047663
Name:DESAI, GAUTAM D (MD)
Entity Type:Individual
Prefix:MR
First Name:GAUTAM
Middle Name:D
Last Name:DESAI
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2020 S INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453
Mailing Address - Country:US
Mailing Address - Phone:757-471-6977
Mailing Address - Fax:757-471-5300
Practice Address - Street 1:2020 S INDEPENDENCE BLVD
Practice Address - Street 2:SUITE #3
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453
Practice Address - Country:US
Practice Address - Phone:757-471-6977
Practice Address - Fax:757-471-5300
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-06-24
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Provider Licenses
StateLicense IDTaxonomies
VA0101045379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080100260OtherRR MEDICARE
VA005628881Medicaid
332419OtherBLUE CROSS/BLUE SHIELD
332419OtherBLUE CROSS/BLUE SHIELD
E18741Medicare UPIN