Provider Demographics
NPI:1164622874
Name:PATEL, GRISHMA PREMAL (OD)
Entity Type:Individual
Prefix:DR
First Name:GRISHMA
Middle Name:PREMAL
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3579
Mailing Address - Country:US
Mailing Address - Phone:630-668-4144
Mailing Address - Fax:630-668-7559
Practice Address - Street 1:1325 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3579
Practice Address - Country:US
Practice Address - Phone:630-668-4144
Practice Address - Fax:630-668-7559
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009678152WC0802X
IL046009678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009678Medicaid
IL6360480001Medicare NSC
ILIL2736Medicare PIN