Provider Demographics
NPI:1487689758
Name:DESAI, VIRENDRA D (MD)
Entity Type:Individual
Prefix:
First Name:VIRENDRA
Middle Name:D
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:PO BOX 741087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1087
Mailing Address - Country:US
Mailing Address - Phone:561-863-3941
Mailing Address - Fax:561-845-6272
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-3523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93419207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA202Medicare PIN