Provider Demographics
NPI:1417238031
Name:PATEL, VIJAYENDRA C
Entity Type:Individual
Prefix:MR
First Name:VIJAYENDRA
Middle Name:C
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 W STATE RD
Mailing Address - Street 2:
Mailing Address - City:ISLAND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60042-8450
Mailing Address - Country:US
Mailing Address - Phone:847-726-1047
Mailing Address - Fax:
Practice Address - Street 1:442 W STATE RD
Practice Address - Street 2:
Practice Address - City:ISLAND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60042-8450
Practice Address - Country:US
Practice Address - Phone:847-487-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist