Provider Demographics
NPI:1952180374
Name:PATEL, KISHAN PANKAJ (OD)
Entity Type:Individual
Prefix:
First Name:KISHAN
Middle Name:PANKAJ
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 CLEARBROOK CT
Mailing Address - Street 2:
Mailing Address - City:SAUGATUCK
Mailing Address - State:MI
Mailing Address - Zip Code:49453-9488
Mailing Address - Country:US
Mailing Address - Phone:201-360-1671
Mailing Address - Fax:
Practice Address - Street 1:4214 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-1293
Practice Address - Country:US
Practice Address - Phone:708-453-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist