Provider Demographics
NPI:1629382809
Name:PATEL, KAUSHIKKUMAR KANTILAL (RPT)
Entity Type:Individual
Prefix:MR
First Name:KAUSHIKKUMAR
Middle Name:KANTILAL
Last Name:PATEL
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49063 GAVIOTA LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1164
Mailing Address - Country:US
Mailing Address - Phone:586-822-0007
Mailing Address - Fax:
Practice Address - Street 1:49063 GAVIOTA LN
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1164
Practice Address - Country:US
Practice Address - Phone:586-822-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501012613Medicaid
MI5501012613OtherSTATE OF MICHIGAN