Provider Demographics
NPI:1861492100
Name:DESAI, SANJIV KISHOR (MD)
Entity Type:Individual
Prefix:
First Name:SANJIV
Middle Name:KISHOR
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 1:116 W BOUGAINVILLEA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7437
Mailing Address - Country:US
Mailing Address - Phone:813-932-4381
Mailing Address - Fax:813-933-6875
Practice Address - Street 1:116 W BOUGAINVILLEA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7437
Practice Address - Country:US
Practice Address - Phone:813-932-4381
Practice Address - Fax:813-933-6875
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 87754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
810446ZMedicare ID - Type Unspecified
I21114Medicare UPIN