Provider Demographics
NPI:1053323758
Name:PATEL, INDRAJIT J (MD)
Entity Type:Individual
Prefix:
First Name:INDRAJIT
Middle Name:J
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-867-5201
Practice Address - Fax:228-867-3152
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042231A207R00000X
MS23437208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01622840OtherBLUE CROSS SHIELD
IL036086539Medicaid
IN492650OtherINDIANA MEDICARE
IN492650OtherINDIANA MEDICARE
MS405699YPX8Medicare PIN
IL036086539Medicaid