Provider Demographics
NPI:1417111303
Name:DESAI, MONALI (MD)
Entity Type:Individual
Prefix:
First Name:MONALI
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
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:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0750
Practice Address - Street 1:2349 LAKE AVE
Practice Address - Street 2:SUITE 99
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7835
Practice Address - Country:US
Practice Address - Phone:574-941-2977
Practice Address - Fax:574-941-2978
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008016699207RC0000X
ND12011207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16044Medicaid
IN000000861818OtherBCBS
NDN716776Medicare PIN
ND16044Medicaid