=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225237142
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIPAK C PATEL O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2007
-----------------------------------------------------
Last Update Date | 07/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2036 PLAZA DR
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-2842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-960-5537
-----------------------------------------------------
Fax | 626-960-5357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2036 PLAZA DR
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-2842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-960-5537
-----------------------------------------------------
Fax | 626-960-5357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9333 TPA
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------