Healthcare Provider Details

I. General information

NPI: 1699256198
Provider Name (Legal Business Name): PALAK J PATEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97825 SHOPPING CENTER AVE
BROOKINGS OR
97415-9403
US

IV. Provider business mailing address

PO BOX 6988
BROOKINGS OR
97415-0355
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-9800
  • Fax: 541-412-9600
Mailing address:
  • Phone: 541-412-9800
  • Fax: 541-412-9600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateOR

VIII. Authorized Official

Name: PALAK J PATEL
Title or Position: OWNER
Credential: MD
Phone: 541-412-9800