Healthcare Provider Details

I. General information

NPI: 1306426093
Provider Name (Legal Business Name): SHIV PRAVIN PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 WILSHIRE BLVD STE 300
SANTA MONICA CA
90401-2066
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-395-5588
  • Fax: 310-395-6313
Mailing address:
  • Phone: 310-301-5138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL86021
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA195003
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: