Healthcare Provider Details

I. General information

NPI: 1356678692
Provider Name (Legal Business Name): SHOUNUCK ISHVER PATEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 CAMPUS DR STE 210
NEWPORT BEACH CA
92660-2111
US

IV. Provider business mailing address

56 STATUARY
IRVINE CA
92620-3551
US

V. Phone/Fax

Practice location:
  • Phone: 310-929-9790
  • Fax: 310-929-9791
Mailing address:
  • Phone: 202-277-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number20A13788
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: