Healthcare Provider Details

I. General information

NPI: 1992704332
Provider Name (Legal Business Name): SAMIR A PATEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date: 03/18/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

415 W CARROLL AVE STE 2ND
GLENDORA CA
91741-4208
US

IV. Provider business mailing address

415 W CARROLL AVE STE 2ND
GLENDORA CA
91741-4208
US

V. Phone/Fax

Practice location:
  • Phone: 909-394-9004
  • Fax:
Mailing address:
  • Phone: 909-394-9004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: