Provider Demographics
NPI:1437122710
Name:DESAI, ANISH A (MD)
Entity Type:Individual
Prefix:
First Name:ANISH
Middle Name:A
Last Name:DESAI
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 1:711 CANTON RD NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8948
Mailing Address - Country:US
Mailing Address - Phone:678-741-5000
Mailing Address - Fax:678-819-4280
Practice Address - Street 1:6002 PROFESSIONAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:678-741-5000
Practice Address - Fax:770-874-0528
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA054483207RG0100X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA266365482AMedicaid
11SCCWJMedicare ID - Type Unspecified
GA266365482AMedicaid