Provider Demographics
NPI:1033169487
Name:PATEL, MANJARI ILESH (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJARI
Middle Name:ILESH
Last Name:PATEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANJARI
Other - Middle Name:P
Other - Last Name:SHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11375 CORTEZ BLVD, STATE RD 50
Mailing Address - Street 2:OAK HILL HOSPITAL
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613
Mailing Address - Country:US
Mailing Address - Phone:352-597-6071
Mailing Address - Fax:352-597-6031
Practice Address - Street 1:11375 CORTEZ BLVD., STATE RD 50
Practice Address - Street 2:OAK HILL HOSPITAL
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613
Practice Address - Country:US
Practice Address - Phone:352-597-6071
Practice Address - Fax:352-597-6031
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90171207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274304300Medicaid
I46658Medicare UPIN
30153WMedicare PIN