Provider Demographics
NPI:1871758177
Name:PATEL, ROSHAN S (MD)
Entity type:Individual
Prefix:DR
First Name:ROSHAN
Middle Name:S
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 1:377 SPOON DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3814
Mailing Address - Country:US
Mailing Address - Phone:773-802-1100
Mailing Address - Fax:
Practice Address - Street 1:98 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1758
Practice Address - Country:US
Practice Address - Phone:208-782-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11088208D00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice