=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538381058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSHIL R PATEL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 SAINT ROSE PKWY
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-3839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-453-3799
-----------------------------------------------------
Fax | 702-453-5741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2660 CRIMSON CANYON DR STE 130
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-0846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-453-3799
-----------------------------------------------------
Fax | 702-453-5741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 12914
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 946156
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 12914
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------