Provider Demographics
NPI:1285619023
Name:PATEL, PURSHOTTAM N (MD)
Entity type:Individual
Prefix:DR
First Name:PURSHOTTAM
Middle Name:N
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 1:1214A LINE ST
Mailing Address - Street 2:STE B
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801-1604
Mailing Address - Country:US
Mailing Address - Phone:570-286-0330
Mailing Address - Fax:570-286-5302
Practice Address - Street 1:1214A LINE ST
Practice Address - Street 2:STE B
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-1604
Practice Address - Country:US
Practice Address - Phone:570-286-0330
Practice Address - Fax:570-286-5302
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037501L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006789640001Medicaid
0000991683OtherKEYSTME
46415OtherBS
7991683OtherGATEWAY
01077301OtherCAPITAL
0000991683OtherKEYSTME
PA0006789640001Medicaid