Provider Demographics
NPI:1902298219
Name:DESA, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:DESA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19386 WOODLANDS DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5541
Mailing Address - Country:US
Mailing Address - Phone:714-536-8930
Mailing Address - Fax:
Practice Address - Street 1:9003 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6709
Practice Address - Country:US
Practice Address - Phone:714-313-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT4907207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program