Healthcare Provider Details

I. General information

NPI: 1255416947
Provider Name (Legal Business Name): KAMLESH PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KAMLESHKUMAR PATEL M.D.

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 CARROLL RD
FORT WAYNE IN
46845-9373
US

IV. Provider business mailing address

1638 CARROLL RD
FORT WAYNE IN
46845-9373
US

V. Phone/Fax

Practice location:
  • Phone: 321-626-3044
  • Fax:
Mailing address:
  • Phone: 321-626-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME85416
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberME85416
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME85416
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: