Provider Demographics
NPI:1821137563
Name:PATEL, DIVYESH GAJU (MD)
Entity Type:Individual
Prefix:DR
First Name:DIVYESH
Middle Name:GAJU
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 1:825 E LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5803
Mailing Address - Country:US
Mailing Address - Phone:219-464-4891
Mailing Address - Fax:219-464-1873
Practice Address - Street 1:825 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5803
Practice Address - Country:US
Practice Address - Phone:219-464-4891
Practice Address - Fax:219-464-1873
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010851942085R0202X
IN01063311A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00413508OtherRR MEDICARE
IN655660FFMedicare PIN
INI41090Medicare UPIN