Individual
CHAMPAK PATEL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5196 HWY 53, BRASELTON, GA 30517
(706) 824-9929
(706) 654-9373
Mailing address
455 BEAVER RUIN RD, LILBURN, GA 30047
(770) 923-7778
(770) 806-1383
Taxonomy
Speciality
Code
Description
License number
State
173000000X
Legal Medicine
Primary
059888
GA
207RP1001X
Pulmonary Disease Physician
123503
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000411428001
BLUE SHIELD
NY
05
—
00525411
—
NY
01
—
11136
MVP
NY
01
—
141618275
TAX ID
NY
01
—
349351
EMPIRE
NY
05
—
554972145A
—
GA
01
—
75786IM
GHI
NY
Enumeration date
02/06/2006
Last updated
06/12/2008
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