Provider Demographics
NPI:1124010426
Name:PATEL, VASANT (MD)
Entity Type:Individual
Prefix:
First Name:VASANT
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:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-639-0678
Practice Address - Street 1:2 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-684-1035
Practice Address - Fax:618-684-1036
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39368208600000X
FLME0099133208600000X
IL036135386208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64096431Medicaid
FL90634OtherBLUE CROSS AND BLUE SHIEL
B96481Medicare UPIN
IL214881Medicare Oscar/Certification
FL90634OtherBLUE CROSS AND BLUE SHIEL