Provider Demographics
NPI:1063428647
Name:DESAI, MANISHA MAHADEV (MD)
Entity type:Individual
Prefix:
First Name:MANISHA
Middle Name:MAHADEV
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 1:808 TOWER DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4239
Mailing Address - Country:US
Mailing Address - Phone:432-580-0985
Mailing Address - Fax:432-337-2666
Practice Address - Street 1:29 DOLORES CT
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8544
Practice Address - Country:US
Practice Address - Phone:432-561-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics