Provider Demographics
NPI:1518051325
Name:DESAI, SURESHCHANDRA N (MD)
Entity Type:Individual
Prefix:
First Name:SURESHCHANDRA
Middle Name:N
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 1:7956 PLANTATION LAKES DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3011
Mailing Address - Country:US
Mailing Address - Phone:772-489-5852
Mailing Address - Fax:
Practice Address - Street 1:4500 W MIDWAY RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-4823
Practice Address - Country:US
Practice Address - Phone:772-468-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME292252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0371467-00Medicaid
24529Medicare ID - Type Unspecified
D65145Medicare UPIN