Provider Demographics
NPI:1992704332
Name:PATEL, SAMIR A (DO)
Entity type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:A
Last Name:PATEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3824
Mailing Address - Country:US
Mailing Address - Phone:217-423-2889
Mailing Address - Fax:217-423-2923
Practice Address - Street 1:1730 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3809
Practice Address - Country:US
Practice Address - Phone:217-329-1000
Practice Address - Fax:217-329-1055
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2021-12-30
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IL036096741208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094812Medicaid
IL036094812Medicaid