Provider Demographics
NPI:1144752254
Name:PATEL, VISHAL
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 ROBLEY DR APT 4208
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5528
Mailing Address - Country:US
Mailing Address - Phone:972-408-6256
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57553207P00000X
390200000X
MS26889207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100858560Medicaid