Provider Demographics
NPI:1972942779
Name:DESAI, KHUSHBU DUSHYANT (MD)
Entity Type:Individual
Prefix:
First Name:KHUSHBU
Middle Name:DUSHYANT
Last Name:DESAI
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:PO BOX 1473
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0473
Mailing Address - Country:US
Mailing Address - Phone:570-208-5534
Mailing Address - Fax:570-208-5548
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18764-0999
Practice Address - Country:US
Practice Address - Phone:570-552-4450
Practice Address - Fax:570-552-4455
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT 204741207Q00000X
PAMD459060208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA530610Medicare PIN