Provider Demographics
NPI:1225701675
Name:PATEL, POOJA M
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:M
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 1:1333 W BELMONT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5785
Mailing Address - Country:US
Mailing Address - Phone:312-694-2273
Mailing Address - Fax:312-694-1875
Practice Address - Street 1:1333 W BELMONT AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5785
Practice Address - Country:US
Practice Address - Phone:312-694-2273
Practice Address - Fax:312-694-1875
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant