Provider Demographics
NPI:1386640415
Name:DESHMUKH, AVI (MD)
Entity type:Individual
Prefix:
First Name:AVI
Middle Name:
Last Name:DESHMUKH
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 1:805 HILL BLVD STE 106-107
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1481
Mailing Address - Country:US
Mailing Address - Phone:817-599-3690
Mailing Address - Fax:817-599-6633
Practice Address - Street 1:805 HILL BLVD STE 106-107
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048
Practice Address - Country:US
Practice Address - Phone:817-599-3690
Practice Address - Fax:817-599-6633
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1067208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340008824OtherRAILROAD MEDICARE PROV NO
TX101878001Medicaid
TN9792483001OtherCIGNA PROVIDER NUMBER
TN814764OtherBCBS PROVIDER NUMBER
TX4458935OtherAETNA PROVIDER NUMBER
TX111591100OtherFIRST CARE PROVIDER NUMBE
TX101878001Medicaid
TXE09252Medicare UPIN