Provider Demographics
NPI:1407977457
Name:DIPAK B PATEL MD LLC
Entity Type:Organization
Organization Name:DIPAK B PATEL MD LLC
Other - Org Name:BUFORD MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANISH
Authorized Official - Middle Name:B
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-271-7680
Mailing Address - Street 1:4745 NELSON BROGDON BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3713
Mailing Address - Country:US
Mailing Address - Phone:770-945-7676
Mailing Address - Fax:770-932-9845
Practice Address - Street 1:4745 NELSON BROGDON BLVD
Practice Address - Street 2:STE 200
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3713
Practice Address - Country:US
Practice Address - Phone:770-945-7676
Practice Address - Fax:770-932-9845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA969140468AMedicaid
H05458Medicare UPIN
GA969140468AMedicaid