Basic Information
Provider Information | |||||||||
NPI: | 1306101415 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YADAV | ||||||||
FirstName: | DEEPAK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2642 TUSCAN HILLS LN | ||||||||
Address2: |   | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880111810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9159294471 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2799 W GRAND BLVD | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482022608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8006536568 | ||||||||
FaxNumber: | 3138761305 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2012 | ||||||||
LastUpdateDate: | 08/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | MD2018-0069 | NM | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2080N0001X | R8513 | TX | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | 4301107188 | MI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.