Provider Demographics
NPI:1760445423
Name:DESAI, SHAILESH DHIRUBHAI (MD)
Entity type:Individual
Prefix:
First Name:SHAILESH
Middle Name:DHIRUBHAI
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:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-0324
Mailing Address - Country:US
Mailing Address - Phone:712-279-5830
Mailing Address - Fax:712-279-5883
Practice Address - Street 1:240 NORTH RERICK AVE
Practice Address - Street 2:
Practice Address - City:PRIMGHAR
Practice Address - State:IA
Practice Address - Zip Code:51245
Practice Address - Country:US
Practice Address - Phone:712-957-2310
Practice Address - Fax:712-957-0504
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2145151Medicaid
IA3145151Medicaid
IA4145151Medicaid
IA5145151Medicaid
IA22768OtherSIOUX VALLEY HEALTH PLAN
IA48073OtherWELLMARK BCBS IA
IA2145151Medicaid