Provider Demographics
NPI:1316981368
Name:DESAI, SANDRA P (DPM)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:P
Last Name:DESAI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12734 KENWOOD LN
Mailing Address - Street 2:SUITE 44
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5666
Mailing Address - Country:US
Mailing Address - Phone:239-936-2454
Mailing Address - Fax:239-936-1974
Practice Address - Street 1:12734 KENWOOD LN
Practice Address - Street 2:SUITE 44
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5666
Practice Address - Country:US
Practice Address - Phone:239-936-2454
Practice Address - Fax:239-936-1974
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2833213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO2833OtherSTATE LICENSE
FL340126000Medicaid
FL650953687OtherTAXID
FL340439100Medicaid
FL650953687OtherTAXID
FLK5353Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
FLE3499AMedicare PIN
FL340439100Medicaid