Healthcare Provider Details

I. General information

NPI: 1205836962
Provider Name (Legal Business Name): DIPA SUMAN PATEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MIDTOWNE ST NE SUITE 301
GRAND RAPIDS MI
49503-5729
US

IV. Provider business mailing address

555 MIDTOWNE ST NE SUITE 301
GRAND RAPIDS MI
49503-5729
US

V. Phone/Fax

Practice location:
  • Phone: 616-248-8864
  • Fax: 616-248-8874
Mailing address:
  • Phone: 616-248-8864
  • Fax: 616-248-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301067695
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: