Provider Demographics
NPI:1275718546
Name:PATEL, MAYUR
Entity Type:Individual
Prefix:
First Name:MAYUR
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 1:1987 STATE ROUTE 52
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-8316
Mailing Address - Country:US
Mailing Address - Phone:845-292-8200
Mailing Address - Fax:845-292-9083
Practice Address - Street 1:1987 STATE ROUTE 52
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-8316
Practice Address - Country:US
Practice Address - Phone:845-292-8200
Practice Address - Fax:845-292-9083
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY46404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01588903Medicaid