Healthcare Provider Details

I. General information

NPI: 1508483447
Provider Name (Legal Business Name): ISHAN SURESH PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 DAVENPORT LN
ROCHESTER HILLS MI
48309-4284
US

IV. Provider business mailing address

3252 DAVENPORT LN
ROCHESTER HILLS MI
48309-4284
US

V. Phone/Fax

Practice location:
  • Phone: 248-229-6355
  • Fax:
Mailing address:
  • Phone: 248-229-6355
  • 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 State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301510057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: