Provider Demographics
NPI:1245345883
Name:DESA, ROOPAL ANIL (MD)
Entity type:Individual
Prefix:
First Name:ROOPAL
Middle Name:ANIL
Last Name:DESA
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 1:3641 HWY 20 SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013
Mailing Address - Country:US
Mailing Address - Phone:770-918-1234
Mailing Address - Fax:770-918-1235
Practice Address - Street 1:3641 HWY 20 SE
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:770-918-1234
Practice Address - Fax:770-918-1235
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035034207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00624511BMedicaid
GA11BDWMJMedicare ID - Type Unspecified
GA00624511BMedicaid
GAGRP6116Medicare ID - Type Unspecified