Healthcare Provider Details

I. General information

NPI: 1619380755
Provider Name (Legal Business Name): SONALI PATEL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 11/10/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W225N16711 CEDAR PARK CT
JACKSON WI
53037-9222
US

IV. Provider business mailing address

W225N16711 CEDAR PARK CT
JACKSON WI
53037-9222
US

V. Phone/Fax

Practice location:
  • Phone: 262-677-1101
  • Fax: 262-677-0121
Mailing address:
  • Phone: 262-677-1101
  • Fax: 262-677-0121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004015A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.010774
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: