Provider Demographics
NPI:1851681134
Name:DEEPTHI S SAXENA MD PC
Entity Type:Organization
Organization Name:DEEPTHI S SAXENA MD PC
Other - Org Name:AVANT-GARDE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPTHI
Authorized Official - Middle Name:S
Authorized Official - Last Name:CULL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-767-0137
Mailing Address - Street 1:4225 LINCOLNSHIRE DR STE B
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2157
Mailing Address - Country:US
Mailing Address - Phone:618-242-2317
Mailing Address - Fax:618-242-9710
Practice Address - Street 1:9355 WARRICK WELLNESS TRL
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-0015
Practice Address - Country:US
Practice Address - Phone:812-476-9983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12455208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15530Medicare UPIN