Provider Demographics
NPI:1073585782
Name:PATEL, CHAMPAK (MD)
Entity Type:Individual
Prefix:
First Name:CHAMPAK
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BEAVER RUIN RD
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:770-923-7778
Mailing Address - Fax:770-806-1383
Practice Address - Street 1:5196 HWY 53
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517
Practice Address - Country:US
Practice Address - Phone:706-824-9929
Practice Address - Fax:706-654-9373
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123503207RP1001X
GA059888173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000411428001OtherBLUE SHIELD
NY00525411Medicaid
NY75786IMOtherGHI
NY11136OtherMVP
NY141618275OtherTAX ID
NY349351OtherEMPIRE
GA554972145AMedicaid
NY000411428001OtherBLUE SHIELD
NYDO1911Medicare UPIN
NY324238BMedicare ID - Type UnspecifiedMEDICARE