Provider Demographics
NPI:1184652125
Name:PATEL, SAMIR PURUSOTTAM (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:PURUSOTTAM
Last Name:PATEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12480 N RANCHO VISTOSO BLVD
Mailing Address - Street 2:STE 180
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-1994
Mailing Address - Country:US
Mailing Address - Phone:520-742-4008
Mailing Address - Fax:
Practice Address - Street 1:12480 N RANCHO VISTOSO BLVD
Practice Address - Street 2:STE 180
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-1994
Practice Address - Country:US
Practice Address - Phone:520-742-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 9750207L00000X
AZ4425207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275925000Medicaid
FLAA118ZMedicare PIN