Provider Demographics
NPI:1689648610
Name:PATEL, PRAKASH J (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:J
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 1:1654 NEWSTONE ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4946
Mailing Address - Country:US
Mailing Address - Phone:717-736-3056
Mailing Address - Fax:
Practice Address - Street 1:1170 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1618
Practice Address - Country:US
Practice Address - Phone:912-920-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72074207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011326860001Medicaid
PAC33084Medicare UPIN
PA187738HL9Medicare PIN