Provider Demographics
NPI:1487642377
Name:DESHMUKH, SANJAY VIJAY (M D)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:VIJAY
Last Name:DESHMUKH
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 E 17TH ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8517
Mailing Address - Country:US
Mailing Address - Phone:714-543-9555
Mailing Address - Fax:714-543-9595
Practice Address - Street 1:1625 E 17TH ST
Practice Address - Street 2:STE. 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8517
Practice Address - Country:US
Practice Address - Phone:714-543-9555
Practice Address - Fax:714-543-9595
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65424174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH17169Medicare UPIN