Provider Demographics
NPI:1215912993
Name:PATEL, PRADIP DIWAKAR (MD)
Entity type:Individual
Prefix:
First Name:PRADIP
Middle Name:DIWAKAR
Last Name:PATEL
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 1:3666 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5543
Mailing Address - Country:US
Mailing Address - Phone:812-238-8880
Mailing Address - Fax:812-478-5384
Practice Address - Street 1:3666 S 4TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5543
Practice Address - Country:US
Practice Address - Phone:812-238-8880
Practice Address - Fax:812-478-5384
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042706174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100473110Medicaid
INF52516Medicare UPIN
IN100473110Medicaid