Provider Demographics
NPI:1043476963
Name:INDRAVADAN T PATEL MD PA
Entity type:Organization
Organization Name:INDRAVADAN T PATEL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:INDRAVADAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-548-6080
Mailing Address - Street 1:2060 OAK TREE RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2058
Mailing Address - Country:US
Mailing Address - Phone:732-548-6080
Mailing Address - Fax:732-744-0796
Practice Address - Street 1:2060 OAK TREE RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-2058
Practice Address - Country:US
Practice Address - Phone:732-548-6080
Practice Address - Fax:732-744-0796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05317400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4986300Medicaid
NJ636031Medicare PIN
NJE62622Medicare UPIN