Provider Demographics
NPI:1629087861
Name:PATEL, ILAXI (DO)
Entity Type:Individual
Prefix:
First Name:ILAXI
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3192
Mailing Address - Country:US
Mailing Address - Phone:815-758-8671
Mailing Address - Fax:
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094572208000000X
IL036-094572207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046887OtherHEALTH ALLIANCE
IL553180OtherMEDICARE GROUP PTAN
IL553180036OtherMEDICARE INDIVIDUAL PTAN
IL036094572Medicaid
IL834340OtherMEDICARE GROUP
IL834340024OtherMEDICARE INDIVIDUAL PTAN
IL553180OtherMEDICARE GROUP PTAN
ILG9755Medicare UPIN
IL036094572Medicaid