Basic Information
| Provider Information | |||||||||
| NPI: | 1407810948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESAI | ||||||||
| FirstName: | RAVI | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | STE 208 | ||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166922160 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 LIMESTONE DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168271616 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 213103 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000526060005 | 01 | NY | BC/BS | OTHER | 02082997 | 05 | NY | MEDICAID | 04110332 | 01 | NY | IHA | OTHER |