Provider Demographics
NPI:1336343540
Name:PATEL, DIMPAL RASHMIKANT (PA-C)
Entity Type:Individual
Prefix:
First Name:DIMPAL
Middle Name:RASHMIKANT
Last Name:PATEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MACK AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2466
Mailing Address - Country:US
Mailing Address - Phone:313-832-0500
Mailing Address - Fax:313-966-8400
Practice Address - Street 1:311 MACK AVE FL 5
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2466
Practice Address - Country:US
Practice Address - Phone:313-832-0500
Practice Address - Fax:313-966-8400
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002968363A00000X
MI5601010654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209119OtherMEDICARE PTAN LOCALITY 16
IL209118OtherMEDICARE PTAN LOCALITY 15
ILK44930Medicare PIN
ILK44931Medicare PIN