1164411724 NPI number — MUKUNDKUMAR V PATEL MD

Table of content: MUKUNDKUMAR V PATEL MD (NPI 1164411724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164411724 NPI number — MUKUNDKUMAR V PATEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATEL
Provider First Name:
MUKUNDKUMAR
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164411724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 ROSECRANS AVE
Provider Second Line Business Mailing Address:
#400
Provider Business Mailing Address City Name:
MANHATTAN BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90266-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-335-4056
Provider Business Mailing Address Fax Number:
310-335-4098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 GAIL GARDNER WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305-1690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-776-1040
Provider Business Practice Location Address Fax Number:
928-776-1040
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  24175 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 355281 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0395860 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 900001128 . This is a "RR MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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