=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245246511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NISHA PATEL DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 01/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1776 YGNACIO VALLEY RD SUITE #102
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94598-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-476-2468
-----------------------------------------------------
Fax | 925-476-1427
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 338 SPEAR ST UNIT 11B
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94105-6172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-953-3053
-----------------------------------------------------
Fax | 925-476-1427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E4657
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------