Provider Demographics
NPI:1861974172
Name:PATEL, SANDIPKUMAR
Entity type:Individual
Prefix:
First Name:SANDIPKUMAR
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16734 S E US HWY 19
Mailing Address - Street 2:
Mailing Address - City:CROSS CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32628
Mailing Address - Country:US
Mailing Address - Phone:352-498-3342
Mailing Address - Fax:352-498-4111
Practice Address - Street 1:16734 S E US HWY 19
Practice Address - Street 2:
Practice Address - City:CROSS CITY
Practice Address - State:FL
Practice Address - Zip Code:32628
Practice Address - Country:US
Practice Address - Phone:352-498-3342
Practice Address - Fax:352-498-4111
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1008307-00Medicaid