Healthcare Provider Details

I. General information

NPI: 1386133759
Provider Name (Legal Business Name): DEVAK PATEL DO, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2968 RODEO PARK DR W STE 150
SANTA FE NM
87505-6383
US

IV. Provider business mailing address

2968 RODEO PARK DR W STE 150
SANTA FE NM
87505-6383
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-5014
  • Fax: 505-982-2687
Mailing address:
  • Phone: 505-982-5014
  • Fax: 505-982-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A21215
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDO2024-0131
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: