Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0203X | Pediatric Critical Care Doctor | 036109253 | IL |
NPI | 1225100977 |
---|---|
Provider Name | Girish Ganesh Deshpande |
First Address | Peoria, IL 61637-0001 |
Second Address | Peoria, IL 61637-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2006 |
Last Update Date | 03/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036109253 | (05) | IL |
07215036 | BCBS (01) | IL |