Provider Demographics
NPI:1861503070
Name:DESIRAJU, BRINDA (MD)
Entity Type:Individual
Prefix:
First Name:BRINDA
Middle Name:
Last Name:DESIRAJU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 PROSPECT AVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-6065
Mailing Address - Country:US
Mailing Address - Phone:718-369-0318
Mailing Address - Fax:718-369-0290
Practice Address - Street 1:220A SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4807
Practice Address - Country:US
Practice Address - Phone:718-821-9262
Practice Address - Fax:718-366-6165
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA68116400207RN0300X
NY238460207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02905911Medicaid
NYA400008171Medicare PIN
NYI65523Medicare UPIN