Provider Demographics
NPI:1255686218
Name:PATEL, KETAN (OD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2385 SUDDABY
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1280
Mailing Address - Country:US
Mailing Address - Phone:714-573-0839
Mailing Address - Fax:
Practice Address - Street 1:18291 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-3408
Practice Address - Country:US
Practice Address - Phone:714-777-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist