Provider Demographics
NPI:1093938979
Name:PATEL, VIRAJ S (MD)
Entity Type:Individual
Prefix:
First Name:VIRAJ
Middle Name:S
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 1:1904 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-7828
Mailing Address - Country:US
Mailing Address - Phone:574-936-3178
Mailing Address - Fax:574-936-1084
Practice Address - Street 1:1904 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7828
Practice Address - Country:US
Practice Address - Phone:574-936-3178
Practice Address - Fax:574-936-1084
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063921A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000637334OtherBC BS OF INDIANA
IN000000669772OtherANTHEM BC BS
IN200868150Medicaid
IN264650CMedicare PIN
IN000000637334OtherBC BS OF INDIANA