Provider Demographics
NPI:1174123194
Name:PATEL, DIPAK
Entity type:Individual
Prefix:
First Name:DIPAK
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 1:9810 AGAVE AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-2137
Mailing Address - Country:US
Mailing Address - Phone:732-421-6533
Mailing Address - Fax:
Practice Address - Street 1:4230 JBS PKWY
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-8153
Practice Address - Country:US
Practice Address - Phone:432-362-0634
Practice Address - Fax:432-362-6345
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX49827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist