Provider Demographics
NPI:1871622969
Name:PATEL, CHANDRAKANT PRAKASH (MD)
Entity type:Individual
Prefix:
First Name:CHANDRAKANT
Middle Name:PRAKASH
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 CRUMPLER BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1946
Mailing Address - Country:US
Mailing Address - Phone:901-826-1345
Mailing Address - Fax:
Practice Address - Street 1:3295 POPLAR AVE STE 105
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4690
Practice Address - Country:US
Practice Address - Phone:901-327-8188
Practice Address - Fax:901-327-8284
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20403207Q00000X
TN59283207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
302I088011Medicare PIN