Provider Demographics
NPI:1376895136
Name:PATEL, DISA
Entity Type:Individual
Prefix:
First Name:DISA
Middle Name:
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 1:14927 AVENIDA ANITA
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-6210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14927 AVENIDA ANITA
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-6210
Practice Address - Country:US
Practice Address - Phone:909-636-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist