Provider Demographics
NPI:1679554901
Name:PATEL, KUNDANBALA (MD)
Entity Type:Individual
Prefix:
First Name:KUNDANBALA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 NORTH WABASH AVE
Mailing Address - Street 2:SUITE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:157 W 8TH ST
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT
Practice Address - State:IN
Practice Address - Zip Code:46928-1012
Practice Address - Country:US
Practice Address - Phone:765-660-7880
Practice Address - Fax:765-671-3511
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031735A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000108718OtherANTHEM BCBS
IN100123620AMedicaid
C24790Medicare UPIN
IN100123620AMedicaid