Healthcare Provider Details

I. General information

NPI: 1174918056
Provider Name (Legal Business Name): BHAVIK HASMUKHBHAI PATEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD STE 210
FORT WAYNE IN
46804
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7355
  • Fax: 260-435-7637
Mailing address:
  • Phone: 260-479-3516
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01080897A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA10382900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: