Healthcare Provider Details

I. General information

NPI: 1316320864
Provider Name (Legal Business Name): KETAN PATEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WATERWORKS WAY STE 240
IRVINE CA
92618-3175
US

IV. Provider business mailing address

113 WATERWORKS WAY STE 240
IRVINE CA
92618-3175
US

V. Phone/Fax

Practice location:
  • Phone: 949-340-9622
  • Fax: 949-528-3969
Mailing address:
  • Phone: 949-340-9622
  • Fax: 949-528-3969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA184155
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA184155
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA10871500
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA184155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: