Provider Demographics
NPI:1144685694
Name:PATEL, KIM (OD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6677 W THUNDERBIRD RD
Mailing Address - Street 2:BLDG F SUITE 101
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3709
Mailing Address - Country:US
Mailing Address - Phone:623-878-3939
Mailing Address - Fax:
Practice Address - Street 1:6677 W THUNDERBIRD RD
Practice Address - Street 2:BLDG F SUITE 101
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3709
Practice Address - Country:US
Practice Address - Phone:623-878-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003110152W00000X
FLOPC5119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018027000Medicaid
FL90IV4OtherBCBS
FL90IV4OtherBCBS
FL97872Medicare PIN