Provider Demographics
NPI:1134103021
Name:PATEL, SMITESH JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:SMITESH
Middle Name:JAY
Last Name:PATEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 CASCADE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2805
Mailing Address - Country:US
Mailing Address - Phone:706-593-0709
Mailing Address - Fax:
Practice Address - Street 1:9220 MARNE RD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5515
Practice Address - Country:US
Practice Address - Phone:706-682-3938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT 1868152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA404896730AMedicaid
GA41ZCFQQMedicare Oscar/Certification