Provider Demographics
NPI:1265830673
Name:PRAJAKTA DESHPANDE, MD
Entity type:Organization
Organization Name:PRAJAKTA DESHPANDE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRAJAKTA
Authorized Official - Middle Name:ABHIJIT
Authorized Official - Last Name:DESHPANDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-252-9150
Mailing Address - Street 1:PO BOX 8051
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-0051
Mailing Address - Country:US
Mailing Address - Phone:714-252-9150
Mailing Address - Fax:714-252-9157
Practice Address - Street 1:6800 LINCOLN AVE
Practice Address - Street 2:SUITE 203 B
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-4162
Practice Address - Country:US
Practice Address - Phone:714-252-9150
Practice Address - Fax:714-252-9157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMD133444207Q00000X, 207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA024822OtherBL