Provider Demographics
NPI:1114910528
Name:PATEL, KETAN (MD)
Entity Type:Individual
Prefix:
First Name:KETAN
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 1:530 PARK AVE E
Mailing Address - Street 2:STE 101
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:815-872-1221
Mailing Address - Fax:815-872-2304
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:STE 101
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3901
Practice Address - Country:US
Practice Address - Phone:815-872-1221
Practice Address - Fax:815-872-2304
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083069Medicaid
IL036083069Medicaid
F23102Medicare UPIN
ILK12369Medicare PIN
F23102Medicare UPIN