Provider Demographics
NPI:1164409090
Name:PATEL, PRAVESH B (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVESH
Middle Name:B
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 1:1520 GERMANTOWN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3318
Mailing Address - Country:US
Mailing Address - Phone:937-222-8111
Mailing Address - Fax:937-222-3019
Practice Address - Street 1:1520 GERMANTOWN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3318
Practice Address - Country:US
Practice Address - Phone:937-222-8111
Practice Address - Fax:937-222-3019
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083993P2084P0800X
IN01049357A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200490910Medicaid
OH2272231Medicaid
IN200490910Medicaid
OH2272231Medicaid
254820Medicare PIN
H49707Medicare UPIN
OHPA4151492Medicare ID - Type Unspecified