Provider Demographics
NPI:1881633071
Name:DESAI, GAUTAM (DO)
Entity Type:Individual
Prefix:MR
First Name:GAUTAM
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1150
Mailing Address - Country:US
Mailing Address - Phone:816-276-7600
Mailing Address - Fax:816-276-7992
Practice Address - Street 1:1010 CARONDELET DR
Practice Address - Street 2:SUITE #220
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4859
Practice Address - Country:US
Practice Address - Phone:816-941-1600
Practice Address - Fax:816-941-1699
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO 119578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO245068309Medicaid
MO245068309Medicaid
230A093Medicare ID - Type Unspecified