Provider Demographics
NPI:1831168988
Name:DESAI, PREMLATA (MD)
Entity type:Individual
Prefix:
First Name:PREMLATA
Middle Name:
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 1:100 RIVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-5030
Mailing Address - Country:US
Mailing Address - Phone:781-255-0555
Mailing Address - Fax:781-255-0594
Practice Address - Street 1:100 RIVER RIDGE DR
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-5030
Practice Address - Country:US
Practice Address - Phone:781-255-0555
Practice Address - Fax:781-255-0594
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39080174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3051757Medicaid
B97778Medicare UPIN
V03241Medicare ID - Type Unspecified