Provider Demographics
NPI:1730193905
Name:PATEL, AMBALAL K (MD)
Entity type:Individual
Prefix:
First Name:AMBALAL
Middle Name:K
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 HANOVER LN
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1926
Mailing Address - Country:US
Mailing Address - Phone:708-957-0634
Mailing Address - Fax:
Practice Address - Street 1:1423 CHICAGO RD
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3400
Practice Address - Country:US
Practice Address - Phone:708-755-3348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619159OtherBLUE CROSS BLUE SHIELD
IL1619159OtherBLUE CROSS BLUE SHIELD
ILD12349Medicare UPIN