Healthcare Provider Details

I. General information

NPI: 1912923079
Provider Name (Legal Business Name): NIRAL PATEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 LAKESIDE VILLAGE LANE
WINDERMERE FL
34786
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 407-876-2273
  • Fax: 407-347-3950
Mailing address:
  • Phone: 407-876-2273
  • Fax: 407-347-3950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-115718
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME106053
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: