Basic Information
| Provider Information | |||||||||
| NPI: | 1447254131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | KETAN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1975 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302694794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785619000 | ||||||||
| FaxNumber: | 7704871232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 HONEY CREEK COMMONS | ||||||||
| Address2: | STE B | ||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300135826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704831100 | ||||||||
| FaxNumber: | 7704835855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 000928 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00915725A | 05 | GA | MEDICAID |