Provider Demographics
NPI:1528793494
Name:PATEL, SIDDHARTH JAGDISHBHAI
Entity type:Individual
Prefix:
First Name:SIDDHARTH
Middle Name:JAGDISHBHAI
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 N HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-2738
Mailing Address - Country:US
Mailing Address - Phone:714-745-2936
Mailing Address - Fax:
Practice Address - Street 1:7501 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:CA
Practice Address - Zip Code:90201-6804
Practice Address - Country:US
Practice Address - Phone:323-771-1706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-23
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA107493Medicaid
CA107493OtherDELTA, CIGNA, AETNA, ANTHEM, SUN LIFE, UNITED HEALTH CARE