Healthcare Provider Details

I. General information

NPI: 1922669548
Provider Name (Legal Business Name): VIRAJ BAKUL PATEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 W ROSECRANS AVE STE 100
HAWTHORNE CA
90250-6686
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 310-643-8500
  • Fax: 310-536-0495
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number20A21726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: