Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 036116885 | IL |
Y | 111NI0900X | Internist | 036116885 | IL |
N | 207X00000X | Orthopaedic Surgeon | 036116885 | IL |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 20A9978 | CA |
NPI | 1215036330 |
---|---|
Provider Name | Sujal Desai |
First Address | Evergreen Park, IL 60805 |
Second Address | Evergreen Park, IL 60805 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 18/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036116885 | STATE OF ILLINOIS LICENSE (01) | IL |
20A9978 | CALIFORNIA STATE LICENSE# (01) | CA |