Provider Demographics
NPI:1104116201
Name:SURENDRA PATEL MD, LLC
Entity type:Organization
Organization Name:SURENDRA PATEL MD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SURENDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-440-1110
Mailing Address - Street 1:5680 N FRESNO ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8331
Mailing Address - Country:US
Mailing Address - Phone:559-440-1110
Mailing Address - Fax:559-440-1114
Practice Address - Street 1:5680 N FRESNO ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8331
Practice Address - Country:US
Practice Address - Phone:559-440-1110
Practice Address - Fax:559-440-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50956261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A509560Medicaid
CAF53223Medicare UPIN