Provider Demographics
NPI:1962502112
Name:PATEL, RODA K (MD)
Entity Type:Individual
Prefix:MRS
First Name:RODA
Middle Name:K
Last Name:PATEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1827
Mailing Address - Country:US
Mailing Address - Phone:718-327-5448
Mailing Address - Fax:
Practice Address - Street 1:1925 CORNAGA AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3513
Practice Address - Country:US
Practice Address - Phone:718-327-5448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123214208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00231645Medicaid
NYC08021Medicare UPIN