Provider Demographics
NPI:1720291024
Name:PATIL, AVINASH SHIVAPUTRAPPA (MD)
Entity type:Individual
Prefix:MR
First Name:AVINASH
Middle Name:SHIVAPUTRAPPA
Last Name:PATIL
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:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO AVE STE 220
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9289
Practice Address - Country:US
Practice Address - Phone:208-302-1100
Practice Address - Fax:208-302-1155
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00729207V00000X, 207VM0101X, 207VM0101X
COCDR.0001513207VM0101X
IDMC-2207207VM0101X
IN01073021A207VM0101X
AZ51869207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ163951Medicaid
AZ163951Medicaid
AZ163951Medicaid
IN896330012Medicare PIN
Z191703Medicare PIN