Provider Demographics
NPI:1447465992
Name:PATEL, PRAMOD N (DPM)
Entity type:Individual
Prefix:
First Name:PRAMOD
Middle Name:N
Last Name:PATEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3192
Mailing Address - Country:US
Mailing Address - Phone:815-758-8671
Mailing Address - Fax:815-758-1731
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:815-758-1731
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005282213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-005282OtherSTATE LICENSE
IL5275700001Medicare NSC
IL016-005282OtherSTATE LICENSE