Provider Demographics
NPI:1619313475
Name:PATEL, VISHAL M
Entity type:Individual
Prefix:
First Name:VISHAL
Middle Name:M
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 1:1716 LAWRENCE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9108
Mailing Address - Country:US
Mailing Address - Phone:920-276-8600
Mailing Address - Fax:920-632-6806
Practice Address - Street 1:1716 LAWRENCE DR STE 103
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9108
Practice Address - Country:US
Practice Address - Phone:920-276-8600
Practice Address - Fax:920-632-6806
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71477207LP2900X, 208VP0014X
OH35.133312207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100090937Medicaid