Provider Demographics
NPI:1548225741
Name:PATEL, KETAN A (MD)
Entity type:Individual
Prefix:DR
First Name:KETAN
Middle Name:A
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 1:14630 S. TAMIAMI TRAIL
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912
Mailing Address - Country:US
Mailing Address - Phone:850-381-3897
Mailing Address - Fax:
Practice Address - Street 1:14630 S. TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-676-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255042300Medicaid
FLME0076020OtherMEDICAL LICENSE
FL255042300Medicaid