Healthcare Provider Details

I. General information

NPI: 1992704332
Provider Name (Legal Business Name): SAMIR A PATEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date: 03/18/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

1730 E LAKE SHORE DR
DECATUR IL
62521-3809
US

IV. Provider business mailing address

1900 E LAKE SHORE DR SUITE 330
DECATUR IL
62521-3824
US

V. Phone/Fax

Practice location:
  • Phone: 217-329-1000
  • Fax: 217-329-1055
Mailing address:
  • Phone: 217-423-2889
  • Fax: 217-423-2923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036096741
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: