Provider Demographics
NPI:1134116585
Name:PATEL, TEJAL S (OD)
Entity Type:Individual
Prefix:DR
First Name:TEJAL
Middle Name:S
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:7715 N GRAND PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9243
Practice Address - Country:US
Practice Address - Phone:309-691-1320
Practice Address - Fax:309-691-1344
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009810Medicaid
ILP00261601OtherMEDICARE RAILROAD
IL046009810OtherILLINOIS DPA LICENSE
IL046009810Medicaid
IL0295700008Medicare NSC
IL046009810OtherILLINOIS DPA LICENSE