Provider Demographics
NPI:1760674147
Name:PATEL, BHAVESHKUMAR RAMESH (OD)
Entity Type:Individual
Prefix:DR
First Name:BHAVESHKUMAR
Middle Name:RAMESH
Last Name:PATEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12584 N BEACH ST
Mailing Address - Street 2:STE122
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4249
Mailing Address - Country:US
Mailing Address - Phone:817-431-4100
Mailing Address - Fax:
Practice Address - Street 1:12584 N BEACH ST
Practice Address - Street 2:STE122
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-4249
Practice Address - Country:US
Practice Address - Phone:817-431-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7124TG152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX290470YSFNMedicare PIN
TX8F7069Medicare UPIN