Provider Demographics
NPI:1487678454
Name:DESAI, DINA (MD)
Entity Type:Individual
Prefix:DR
First Name:DINA
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 1:7050 MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5548
Mailing Address - Country:US
Mailing Address - Phone:630-889-8922
Mailing Address - Fax:630-424-0021
Practice Address - Street 1:7050 S MADISON ST
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5548
Practice Address - Country:US
Practice Address - Phone:630-889-8922
Practice Address - Fax:630-424-0021
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085129Medicaid
IL036085129Medicaid
ILF55713Medicare UPIN