Provider Demographics
NPI:1548464696
Name:DESAI, MANDAR PRAMOD (MD)
Entity type:Individual
Prefix:
First Name:MANDAR
Middle Name:PRAMOD
Last Name:DESAI
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 1:906 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4237
Mailing Address - Country:US
Mailing Address - Phone:757-553-7099
Mailing Address - Fax:
Practice Address - Street 1:901 W BEN WHITE BLVD
Practice Address - Street 2:SOUTH AUSTIN MEDICAL CENTER
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6903
Practice Address - Country:US
Practice Address - Phone:512-447-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN11660207P00000X
GA063312207P00000X
FLME105634207P00000X
TXN6856207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOTH000Medicare UPIN