Provider Demographics
NPI:1922140615
Name:DESHPANDE, AMOL SUDHAKAR (MD)
Entity Type:Individual
Prefix:
First Name:AMOL
Middle Name:SUDHAKAR
Last Name:DESHPANDE
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 1:103 HAWTHORN
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5361
Mailing Address - Country:US
Mailing Address - Phone:936-634-2128
Mailing Address - Fax:936-594-0491
Practice Address - Street 1:315 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:TX
Practice Address - Zip Code:75862-6202
Practice Address - Country:US
Practice Address - Phone:936-594-7375
Practice Address - Fax:936-594-3797
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5089208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029685702Medicaid
TX029685702Medicaid
86512JMedicare ID - Type Unspecified