Provider Demographics
NPI:1275567166
Name:PATEL, RUTVIK S (MD)
Entity Type:Individual
Prefix:
First Name:RUTVIK
Middle Name:S
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:217-714-0220
Practice Address - Fax:888-366-1712
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062298208M00000X
IN01062298A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2679847Medicaid
IN11589279OtherCAQH
IN200825660Medicaid
IN000000483128OtherANTHEM
IN200825660Medicaid
IN260690VVMedicare PIN
OH2679847Medicaid
IN260690VVMedicare PIN