Provider Demographics
NPI:1568041978
Name:PATEL, PUJA
Entity type:Individual
Prefix:
First Name:PUJA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 N FROLIC AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-3592
Mailing Address - Country:US
Mailing Address - Phone:847-338-7028
Mailing Address - Fax:
Practice Address - Street 1:4663 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2540
Practice Address - Country:US
Practice Address - Phone:708-636-0600
Practice Address - Fax:708-636-0606
Is Sole Proprietor?:No
Enumeration Date:2021-04-04
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46011605152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program