Provider Demographics
NPI: | 1467834879 |
---|---|
Name: | PATEL, SHIVAM |
Entity Type: | Individual |
Prefix: | |
First Name: | SHIVAM |
Middle Name: | |
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: | 1 JARRETT WHITE RD |
Mailing Address - Street 2: | TRIPLER ARMY MEDICAL CENTER |
Mailing Address - City: | TRIPLER ARMY MEDICAL CENTER |
Mailing Address - State: | HI |
Mailing Address - Zip Code: | 96859-5001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 7600 BEECHNUT ST |
Practice Address - Street 2: | |
Practice Address - City: | HOUSTON |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77074-4302 |
Practice Address - Country: | US |
Practice Address - Phone: | 713-456-5686 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-06-22 |
Last Update Date: | 2023-02-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | S8232 | 207R00000X, 208M00000X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VAD000 | Medicare UPIN |