Provider Demographics
NPI:1881699080
Name:DESAI, MANISH I (DO)
Entity type:Individual
Prefix:DR
First Name:MANISH
Middle Name:I
Last Name:DESAI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5909 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-4163
Mailing Address - Country:US
Mailing Address - Phone:708-652-2040
Mailing Address - Fax:708-652-0058
Practice Address - Street 1:5909 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-4163
Practice Address - Country:US
Practice Address - Phone:708-652-2040
Practice Address - Fax:708-652-0058
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105725207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105725OtherBLUE SHIELD
IL843OtherCHICAGO HEALTH SYSTEMS (CHS)
IL289581OtherWELLCARE HMO
IL036105725Medicaid
IL110234946OtherRR MEDICARE PIN
IL036105725Medicaid
ILK26892Medicare PIN
IL036105725OtherBLUE SHIELD