Healthcare Provider Details

I. General information

NPI: 1053931493
Provider Name (Legal Business Name): ISHAN PATEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 REEF DR
CANTON MI
48187-0105
US

IV. Provider business mailing address

667 REEF DR
CANTON MI
48187-0105
US

V. Phone/Fax

Practice location:
  • Phone: 734-512-7777
  • Fax:
Mailing address:
  • Phone: 734-512-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01099195A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: