Provider Demographics
NPI:1205094802
Name:PATEL, PRUTHA (MD)
Entity type:Individual
Prefix:DR
First Name:PRUTHA
Middle Name:
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 1:1365 WESTGATE CENTER DR STE M1
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3106
Mailing Address - Country:US
Mailing Address - Phone:609-992-9529
Mailing Address - Fax:
Practice Address - Street 1:2475 HILLCREST CENTER CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3048
Practice Address - Country:US
Practice Address - Phone:609-992-9529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01023208100000X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2012-01023OtherNC LICENSE NUMBER