Provider Demographics
NPI:1316320864
Name:PATEL, KETAN (MD)
Entity type:Individual
Prefix:
First Name:KETAN
Middle Name:
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 1:2720 N HARBOR BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2626
Mailing Address - Country:US
Mailing Address - Phone:714-446-5192
Mailing Address - Fax:732-515-8360
Practice Address - Street 1:2720 N HARBOR BLVD STE 210
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2626
Practice Address - Country:US
Practice Address - Phone:714-446-5192
Practice Address - Fax:714-446-5169
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA184155208100000X, 208VP0014X, 208VP0000X
NJ25MA108715002081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine