Provider Demographics
NPI:1649395666
Name:DESHPANDE, GAUTAM ANIL (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:ANIL
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 1:1025 WILDER AVE APT 12A
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-2670
Mailing Address - Country:US
Mailing Address - Phone:832-215-3120
Mailing Address - Fax:
Practice Address - Street 1:347 N KUAKINI ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2336
Practice Address - Country:US
Practice Address - Phone:808-547-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96011207R00000X
HI14365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH103455Medicare PIN