Provider Demographics
NPI:1164508867
Name:PATEL, KETAN R (MD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:R
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-4293
Mailing Address - Country:US
Mailing Address - Phone:856-825-5932
Mailing Address - Fax:856-825-4819
Practice Address - Street 1:10 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-4293
Practice Address - Country:US
Practice Address - Phone:856-825-5932
Practice Address - Fax:856-825-4819
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA6269600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6645801Medicaid