Provider Demographics
NPI:1194839357
Name:DESAI, SHAILESH KANTILAL (MD)
Entity type:Individual
Prefix:
First Name:SHAILESH
Middle Name:KANTILAL
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 1:681 DOUGLAS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2583
Mailing Address - Country:US
Mailing Address - Phone:407-774-9555
Mailing Address - Fax:407-774-6774
Practice Address - Street 1:681 DOUGLAS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2583
Practice Address - Country:US
Practice Address - Phone:407-774-9555
Practice Address - Fax:407-774-6774
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 67583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37733290Medicaid
FLF67284Medicare UPIN
FL37733290Medicaid