Provider Demographics
NPI:1750729240
Name:PATEL, ROSHAN K (MD)
Entity type:Individual
Prefix:DR
First Name:ROSHAN
Middle Name:K
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6021
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:
Practice Address - Street 1:515 W STATE ROAD 434
Practice Address - Street 2:SUITE 110
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4981
Practice Address - Country:US
Practice Address - Phone:407-830-8600
Practice Address - Fax:407-830-5110
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-063430207Q00000X
FLME126754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017990500Medicaid
FLIQ631ZMedicare PIN