Provider Demographics
NPI:1699025486
Name:PATEL, CHARU (OD)
Entity Type:Individual
Prefix:
First Name:CHARU
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 HARRISON AVE
Mailing Address - Street 2:SUITE E265
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1017
Mailing Address - Country:US
Mailing Address - Phone:815-332-2223
Mailing Address - Fax:815-332-4488
Practice Address - Street 1:7200 HARRISON AVE
Practice Address - Street 2:SUITE E265
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1017
Practice Address - Country:US
Practice Address - Phone:815-332-2223
Practice Address - Fax:815-332-4488
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010604152W00000X
IN18003748A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist