Basic Information
| Provider Information | |||||||||
| NPI: | 1396164513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | PRATIK | ||||||||
| MiddleName: | P | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100374 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326101544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650291 | ||||||||
| FaxNumber: | 3522650279 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326101544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650291 | ||||||||
| FaxNumber: | 3522650279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D0087099 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME145877 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 222827100 | 05 | MD | MEDICAID | 074487371 | 05 | DC | MEDICAID |