Provider Demographics
NPI:1437190410
Name:DESAI, MANOJ R (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:R
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 1:717 W XENIA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-4930
Mailing Address - Country:US
Mailing Address - Phone:937-878-4531
Mailing Address - Fax:937-878-4070
Practice Address - Street 1:717 W XENIA DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-4930
Practice Address - Country:US
Practice Address - Phone:937-878-4531
Practice Address - Fax:937-878-4070
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0347879Medicaid
OH311358549060OtherCARESOURCE
OH000000387039OtherANTHEM
4242852OtherAETNA
OH0347879Medicaid
4242852OtherAETNA
OH0439837Medicare PIN