Provider Demographics
NPI:1093701674
Name:PATEL, MITULKUMAR P (MD)
Entity Type:Individual
Prefix:
First Name:MITULKUMAR
Middle Name:P
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:PO BOX 1737
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89125-1737
Mailing Address - Country:US
Mailing Address - Phone:702-671-6809
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:4880 WYNN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5406
Practice Address - Country:US
Practice Address - Phone:702-871-5005
Practice Address - Fax:702-671-6883
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10855207R00000X
CAG74858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507193Medicaid
NVCS12512OtherPHARMACY/CONTROLLED SUBSTANCE CERTIFICATE
NV10855OtherMEDICAL LICENSE
NV10855OtherMEDICAL LICENSE
NVVAW945WMedicare PIN
NV10855OtherMEDICAL LICENSE