1255542262 NPI number — DR. VISHAL CHANDUBHAI PATEL MD

Table of content: DR. VISHAL CHANDUBHAI PATEL MD (NPI 1255542262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255542262 NPI number — DR. VISHAL CHANDUBHAI PATEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATEL
Provider First Name:
VISHAL
Provider Middle Name:
CHANDUBHAI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255542262
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2220 COUNTY ROAD 210 WEST
Provider Second Line Business Mailing Address:
STE 108, PMB 257
Provider Business Mailing Address City Name:
ST JOHNS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32259-4060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-687-1055
Provider Business Mailing Address Fax Number:
904-687-2141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8833 PERIMETER PARK BLVD
Provider Second Line Business Practice Location Address:
STE 503
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-687-1055
Provider Business Practice Location Address Fax Number:
904-687-2141
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  29685 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME121788 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108669600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12314503 . This is a "CAQH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 108669600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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