Healthcare Provider Details

I. General information

NPI: 1104146117
Provider Name (Legal Business Name): KETAN N PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 COOPER ST FL 1
FORT WORTH TX
76104-2710
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-6179
  • Fax: 682-885-2874
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN3236
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberN3236
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: