Provider Demographics
NPI:1790942852
Name:PATIL, VIVEK A (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:A
Last Name:PATIL
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 791372
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6420 ROCKLEDGE DR
Practice Address - Street 2:SUITE 2200
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-7837
Practice Address - Country:US
Practice Address - Phone:301-897-8650
Practice Address - Fax:301-530-6810
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0068027208600000X
MDD68027208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
MD416193900Medicaid
MD416193900Medicaid