Healthcare Provider Details

I. General information

NPI: 1063482768
Provider Name (Legal Business Name): KETUL J PATEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 NORTH ST
GENEVA NY
14456-1651
US

IV. Provider business mailing address

202 TAUGHANNOCK BLVD PO BOX 366
ITHACA NY
14850-3328
US

V. Phone/Fax

Practice location:
  • Phone: 315-787-4533
  • Fax: 315-787-4469
Mailing address:
  • Phone: 607-277-4035
  • Fax: 607-277-3888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number229929
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: