Provider Demographics
NPI:1265748404
Name:PATEL, SURENDRA (MD)
Entity type:Individual
Prefix:
First Name:SURENDRA
Middle Name:
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:N20W22961 WATERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1306
Mailing Address - Country:US
Mailing Address - Phone:262-875-5070
Mailing Address - Fax:866-384-9486
Practice Address - Street 1:N20W22961 WATERTOWN RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1306
Practice Address - Country:US
Practice Address - Phone:262-875-5070
Practice Address - Fax:866-384-9486
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56944207R00000X
IL125056488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1265748404Medicaid
WI1265748404Medicaid
WI680861198Medicare PIN