Provider Demographics
NPI:1487173357
Name:MANISHA DESAI
Entity type:Organization
Organization Name:MANISHA DESAI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZATION OWNER/PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:MANISHA
Authorized Official - Middle Name:MAHADEV
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-580-0985
Mailing Address - Street 1:420 EAST 6TH STREET STE 100
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-6947
Mailing Address - Country:US
Mailing Address - Phone:432-580-0985
Mailing Address - Fax:432-337-2666
Practice Address - Street 1:400 EAST 6TH STREET STE 100
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-6947
Practice Address - Country:US
Practice Address - Phone:432-580-0985
Practice Address - Fax:432-337-2666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX09226801Medicaid
TX09226802Medicaid