Healthcare Provider Details

I. General information

NPI: 1710243209
Provider Name (Legal Business Name): ANISH JAGDISH PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18436 ROSCOE BLVD
NORTHRIDGE CA
91325
US

IV. Provider business mailing address

4100 GUARDIAN ST STE 205
SIMI VALLEY CA
93063-6721
US

V. Phone/Fax

Practice location:
  • Phone: 818-435-1433
  • Fax:
Mailing address:
  • Phone: 855-504-4544
  • Fax: 805-577-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA149077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: