Basic Information
| Provider Information | |||||||||
| NPI: | 1861696262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEOSKAR | ||||||||
| FirstName: | DHANANJAY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD, FAAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 OLD OLIVE WAY APT 416 | ||||||||
| Address2: | |||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164662063 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036148243 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 57011356 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 10828 | ND | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 036148243 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14805 | 05 | ND | MEDICAID |