Basic Information
| Provider Information | |||||||||
| NPI: | 1144216318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESAI | ||||||||
| FirstName: | SUVAS | ||||||||
| MiddleName: | GHELABHAI | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065980983 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065981688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | Other Service Providers | Specialist | 208800000X | 16723 | KY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000000045887 | 01 | KY | ANTHEM | OTHER | 64167232 | 05 | KY | MEDICAID |