Provider Demographics
NPI:1730716796
Name:DESHPANDE, PUSHKAR
Entity type:Individual
Prefix:
First Name:PUSHKAR
Middle Name:
Last Name:DESHPANDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:12850 MIDDLEBROOK ROAD, SUITE 250
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-5278
Practice Address - Country:US
Practice Address - Phone:703-729-3420
Practice Address - Fax:703-729-3422
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102208771207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1730716796Medicaid
VA30018029090001Medicaid