Provider Demographics
NPI:1629058680
Name:DESHPANDE, AJAY D (MD)
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:D
Last Name:DESHPANDE
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 1:4320 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4301
Mailing Address - Country:US
Mailing Address - Phone:812-917-0047
Mailing Address - Fax:812-917-0051
Practice Address - Street 1:4320 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4301
Practice Address - Country:US
Practice Address - Phone:812-917-0047
Practice Address - Fax:812-917-0051
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052847A207R00000X, 208D00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000200983OtherBLUE CROSS PROVIDER #
IN200314660Medicaid
IN182180DMedicare ID - Type Unspecified
IN200314660Medicaid