Provider Demographics
NPI:1750669172
Name:PATEL, GAUTAMKUMAR BABULAL
Entity Type:Individual
Prefix:
First Name:GAUTAMKUMAR
Middle Name:BABULAL
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 PAUL HUFF PKWY NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2957
Mailing Address - Country:US
Mailing Address - Phone:423-476-7116
Mailing Address - Fax:423-476-9244
Practice Address - Street 1:578 PAUL HUFF PKWY NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-2957
Practice Address - Country:US
Practice Address - Phone:423-476-7116
Practice Address - Fax:423-476-9244
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000028054183500000X
MI5302037069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist