Provider Demographics
NPI:1700809613
Name:PATEL, PRAVINA THAKOR (RD)
Entity Type:Individual
Prefix:MRS
First Name:PRAVINA
Middle Name:THAKOR
Last Name:PATEL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 LARCH ST
Mailing Address - Street 2:
Mailing Address - City:CARTERET
Mailing Address - State:NJ
Mailing Address - Zip Code:07008-2470
Mailing Address - Country:US
Mailing Address - Phone:732-969-9739
Mailing Address - Fax:732-969-9739
Practice Address - Street 1:39 LARCH ST
Practice Address - Street 2:
Practice Address - City:CARTERET
Practice Address - State:NJ
Practice Address - Zip Code:07008-2470
Practice Address - Country:US
Practice Address - Phone:732-969-9739
Practice Address - Fax:732-969-9739
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL814113133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ054327Medicare ID - Type Unspecified