Provider Demographics
NPI:1912953340
Name:DESAI, KETAN N (DO)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:N
Last Name:DESAI
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3820 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1110
Mailing Address - Country:US
Mailing Address - Phone:770-941-7196
Mailing Address - Fax:770-941-7196
Practice Address - Street 1:3820 MEDICAL PARK DR
Practice Address - Street 2:SUITE 2200
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1110
Practice Address - Country:US
Practice Address - Phone:770-941-7741
Practice Address - Fax:770-941-7196
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-05-03
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Provider Licenses
StateLicense IDTaxonomies
GA57600207R00000X
GA057600207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I53622Medicare UPIN
GA612687622Medicaid
GA511I060050Medicare PIN