Provider Demographics
NPI: | 1629399829 |
---|---|
Name: | DESAI, PINGAL ANILBHAI (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | PINGAL |
Middle Name: | ANILBHAI |
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: | PO BOX 1215 |
Mailing Address - Street 2: | ATTN: CLINIC BILLING OFFICE |
Mailing Address - City: | LIBERAL |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 67905-1215 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 620-629-6638 |
Mailing Address - Fax: | 620-629-6684 |
Practice Address - Street 1: | 305 W 15TH ST STE 102 |
Practice Address - Street 2: | |
Practice Address - City: | LIBERAL |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67901-2455 |
Practice Address - Country: | US |
Practice Address - Phone: | 620-624-0723 |
Practice Address - Fax: | 620-624-2569 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-06-22 |
Last Update Date: | 2020-01-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0101252656 | 207X00000X |
TX | S1387 | 207X00000X |
KS | 0439665 | 207XX0005X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KS | 201152140A | Medicaid |