Provider Demographics
NPI:1518926419
Name:SARDESAI, NITIN (MD)
Entity Type:Individual
Prefix:
First Name:NITIN
Middle Name:
Last Name:SARDESAI
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 1:9307 CALUMET AVE
Mailing Address - Street 2:SUITE D1
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-836-2055
Mailing Address - Fax:219-836-0355
Practice Address - Street 1:9307 CALUMET AVE
Practice Address - Street 2:SUITE D1
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-836-2055
Practice Address - Fax:219-836-0355
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029300207Q00000X
IN01029300A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100200740Medicaid
IN100200740AMedicaid
D15543Medicare UPIN
IN100200740AMedicaid