Provider Demographics
NPI:1619929502
Name:DESAI, BRENA MANISH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENA
Middle Name:MANISH
Last Name:DESAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRENA
Other - Middle Name:BHARATKUMAR
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15715 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2353
Mailing Address - Country:US
Mailing Address - Phone:718-445-3029
Mailing Address - Fax:718-445-2889
Practice Address - Street 1:15715 46TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2353
Practice Address - Country:US
Practice Address - Phone:718-445-3029
Practice Address - Fax:718-445-2889
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225205207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02286208Medicaid
H65555Medicare UPIN
NY6504EMMedicare ID - Type Unspecified