Provider Demographics
NPI:1427084839
Name:DESAGANI, KISHORE K (MD)
Entity type:Individual
Prefix:
First Name:KISHORE
Middle Name:K
Last Name:DESAGANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4199 CAMPUS DR STE 550
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-4694
Mailing Address - Country:US
Mailing Address - Phone:949-689-0288
Mailing Address - Fax:949-509-6599
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:949-689-0288
Practice Address - Fax:949-509-6599
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA996662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC267552Medicaid
SCAA05643353Medicare PIN
SCI12558Medicare UPIN