Provider Demographics
NPI:1932446218
Name:DESAI, JAGDISH (MD)
Entity Type:Individual
Prefix:
First Name:JAGDISH
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:224-430-3545
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS237242080N0001X
MI4301100126208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00882811Medicaid
MS00882811Medicaid