Provider Demographics
NPI:1912054206
Name:DESAI, TEJAL HARESH (AA)
Entity Type:Individual
Prefix:
First Name:TEJAL
Middle Name:HARESH
Last Name:DESAI
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 WEST PARK COURT
Mailing Address - Street 2:SUITE A
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3555
Mailing Address - Country:US
Mailing Address - Phone:678-514-2640
Mailing Address - Fax:
Practice Address - Street 1:2171 WEST PARK COURT
Practice Address - Street 2:SUITE A
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3555
Practice Address - Country:US
Practice Address - Phone:678-514-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003950367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00591324JMedicaid
GA00591324JMedicaid