Provider Demographics
NPI:1669938148
Name:VISHAL K PATEL OD PC
Entity type:Organization
Organization Name:VISHAL K PATEL OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VISHAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-501-0319
Mailing Address - Street 1:1802 E BASSWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1810
Mailing Address - Country:US
Mailing Address - Phone:847-501-0319
Mailing Address - Fax:
Practice Address - Street 1:137 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2316
Practice Address - Country:US
Practice Address - Phone:847-501-0319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISHAL K PATEL OD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010655Medicaid