Healthcare Provider Details

I. General information

NPI: 1184243644
Provider Name (Legal Business Name): KRISTY PRAKASH PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 07/08/2023
Certification Date: 07/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST
DETROIT MI
48201-2119
US

IV. Provider business mailing address

3901 BEAUBIEN ST
DETROIT MI
48201-2196
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-7496
  • Fax: 313-993-7118
Mailing address:
  • Phone: 313-745-7496
  • Fax: 313-993-7118

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 State
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number4301509557
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: