Provider Demographics
NPI:1205836962
Name:PATEL, DIPA SUMAN (MD)
Entity Type:Individual
Prefix:
First Name:DIPA
Middle Name:SUMAN
Last Name:PATEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MIDTOWNE ST NE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5729
Mailing Address - Country:US
Mailing Address - Phone:616-248-8864
Mailing Address - Fax:616-248-8874
Practice Address - Street 1:555 MIDTOWNE ST NE
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5729
Practice Address - Country:US
Practice Address - Phone:616-248-8864
Practice Address - Fax:616-248-8874
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067695207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4687596Medicaid
MI4217043Medicaid
MI4687596Medicaid
MIN13100001Medicare ID - Type UnspecifiedDERMATOLOGY CENTER
H18765Medicare UPIN
MI4217043Medicaid