Provider Demographics
NPI:1164411724
Name:PATEL, MUKUNDKUMAR V (MD)
Entity Type:Individual
Prefix:
First Name:MUKUNDKUMAR
Middle Name:V
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 ROSECRANS AVE
Mailing Address - Street 2:#400
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-3763
Mailing Address - Country:US
Mailing Address - Phone:310-335-4056
Mailing Address - Fax:310-335-4098
Practice Address - Street 1:1100 GAIL GARDNER WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1690
Practice Address - Country:US
Practice Address - Phone:928-776-1040
Practice Address - Fax:928-776-1040
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ24175207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ355281Medicaid
AZAZ0395860OtherBCBS
AZ900001128OtherRR MEDICARE
WMBPL02Medicare ID - Type Unspecified
AZ900001128OtherRR MEDICARE