Provider Demographics
NPI:1669740114
Name:PATEL, AMITA (OD)
Entity type:Individual
Prefix:
First Name:AMITA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 SOUTH ST
Mailing Address - Street 2:ST 121
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11900 SOUTH ST
Practice Address - Street 2:ST 121
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6847
Practice Address - Country:US
Practice Address - Phone:562-809-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13974 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist