Provider Demographics
NPI:1700093457
Name:DR AMI PATEL, OPTOMETRIST
Entity Type:Organization
Organization Name:DR AMI PATEL, OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMI
Authorized Official - Middle Name:T
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-598-4393
Mailing Address - Street 1:2771 S DIAMOND BAR BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2771 S DIAMOND BAR BLVD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3513
Practice Address - Country:US
Practice Address - Phone:909-598-4393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9067T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005350Medicaid
CAGSD005350Medicaid
CAWY133Medicare PIN