Provider Demographics
NPI:1164870333
Name:PATEL, CHANDNI
Entity Type:Individual
Prefix:
First Name:CHANDNI
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 HOBART DR
Mailing Address - Street 2:UNIT B
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3086
Mailing Address - Country:US
Mailing Address - Phone:618-218-7117
Mailing Address - Fax:
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-759-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-29
Last Update Date:2016-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.297044183500000X
WI17297-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist