Basic Information
| Provider Information | |||||||||
| NPI: | 1194769398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | PRATIMA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 01 BROADWAY | ||||||||
| Address2: | ROOM A1-9 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183344952 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 01 BROADWAY | ||||||||
| Address2: | ROOM A1-9 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183344952 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 121706 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | #OO351717 | 05 | NY | MEDICAID |