Provider Demographics
NPI:1629040852
Name:DESAI, VAJENDRA J (MD)
Entity Type:Individual
Prefix:
First Name:VAJENDRA
Middle Name:J
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 1:1055 MEDICAL PARK DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3607
Mailing Address - Country:US
Mailing Address - Phone:616-957-2235
Mailing Address - Fax:616-464-4234
Practice Address - Street 1:1055 MEDICAL PARK DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3607
Practice Address - Country:US
Practice Address - Phone:616-957-2235
Practice Address - Fax:616-464-4234
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010371722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2574806Medicaid
MI2574806Medicaid
MIMI1271Medicare PIN
MI0P28140001Medicare ID - Type Unspecified