Healthcare Provider Details

I. General information

NPI: 1053663096
Provider Name (Legal Business Name): DHAVAL H PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 CENTRE LAKE DR
ONTARIO CA
91761-1211
US

IV. Provider business mailing address

3330 CENTRE LAKE DR
ONTARIO CA
91761-1211
US

V. Phone/Fax

Practice location:
  • Phone: 866-205-3595
  • Fax:
Mailing address:
  • Phone: 866-205-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberA136932
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: