Provider Demographics
NPI:1679764054
Name:PATEL, GAUTAM GHANSHYAMBHAI (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:GHANSHYAMBHAI
Last Name:PATEL
Suffix:
Gender:M
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5416
Mailing Address - Fax:704-384-5992
Practice Address - Street 1:1500 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4656
Practice Address - Country:US
Practice Address - Phone:704-384-5416
Practice Address - Fax:704-384-5992
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01202207Q00000X, 208M00000X
KYR1569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC0630DOtherMEDICARE PIN, INDIV UNDER CHG-WILKES
NC1679764054Medicaid
NC1679764054Medicaid
NCNC0630DOtherMEDICARE PIN, INDIV UNDER CHG-WILKES