Provider Demographics
NPI:1821766940
Name:DESAI, ASHINI (PA)
Entity Type:Individual
Prefix:
First Name:ASHINI
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E GRAND AVE APT O12
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3535
Mailing Address - Country:US
Mailing Address - Phone:803-603-1585
Mailing Address - Fax:
Practice Address - Street 1:5835 IL-154
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-2907
Practice Address - Country:US
Practice Address - Phone:803-603-1585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085.008623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program