Provider Demographics
NPI:1609032986
Name:PATEL, MITA B (MD)
Entity type:Individual
Prefix:
First Name:MITA
Middle Name:B
Last Name:PATEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF CARDIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6777
Mailing Address - Fax:
Practice Address - Street 1:4676 ADMIRALTY WAY # 301
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6601
Practice Address - Country:US
Practice Address - Phone:310-673-3945
Practice Address - Fax:310-673-0273
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64496207R00000X
IL125.054484207R00000X
CAA150310207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1609032986Medicaid