Provider Demographics
NPI:1992753859
Name:PATEL, PRATUL (MD)
Entity type:Individual
Prefix:
First Name:PRATUL
Middle Name:
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 1:601 E FRONT AVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2701
Mailing Address - Country:US
Mailing Address - Phone:866-400-4295
Mailing Address - Fax:208-763-3644
Practice Address - Street 1:4519 WESTWAY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3632
Practice Address - Country:US
Practice Address - Phone:214-559-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ01812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1548537Medicaid
G26474Medicare UPIN
TXTXB101027Medicare PIN
LA1548537Medicaid