Provider Demographics
NPI:1992252944
Name:DESAI, JAGDISH
Entity type:Individual
Prefix:
First Name:JAGDISH
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAGDISH
Other - Middle Name:P
Other - Last Name:DESAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1608 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60636-3316
Mailing Address - Country:US
Mailing Address - Phone:773-778-3420
Mailing Address - Fax:
Practice Address - Street 1:1608 W 69TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60636-3316
Practice Address - Country:US
Practice Address - Phone:773-778-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-033681183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364309678Medicaid