Basic Information
| Provider Information | |||||||||
| NPI: | 1922056357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | MANISH | ||||||||
| MiddleName: | PRAHLAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134326 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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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 | 207Q00000X | L8159 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1766206-01 | 05 | TX | MEDICAID | 8D9548 | 01 | TX | MEDICARE PTAN | OTHER | L8159 | 01 | TX | STATE MEDICAL LICENSE | OTHER |