Provider Demographics
NPI:1821012030
Name:DESAI, CHETNA VIPUL (PT)
Entity type:Individual
Prefix:MS
First Name:CHETNA
Middle Name:VIPUL
Last Name:DESAI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4655 DOBIE RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2233
Mailing Address - Country:US
Mailing Address - Phone:517-282-7107
Mailing Address - Fax:
Practice Address - Street 1:4655 DOBIE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2233
Practice Address - Country:US
Practice Address - Phone:517-282-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005992174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501005992OtherMI LICENSE NUMBER
MI650C31212OtherMIBLUE CROSS BLUE SHIELD
MI0N80240Medicare ID - Type Unspecified