Healthcare Provider Details

I. General information

NPI: 1285045294
Provider Name (Legal Business Name): HETAL PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 ALPINE AVE NW
GRAND RAPIDS MI
49544-1956
US

IV. Provider business mailing address

3303 S CREEK DR SE # 303
KENTWOOD MI
49512-3069
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-6010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number5302036772
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: