Provider Demographics
NPI:1780319145
Name:PATEL, SHIVANI KAMLESH
Entity type:Individual
Prefix:
First Name:SHIVANI
Middle Name:KAMLESH
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1000 E OGDEN AVE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8616
Practice Address - Country:US
Practice Address - Phone:630-355-9080
Practice Address - Fax:630-355-9179
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL046011700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program