Provider Demographics
NPI:1316191018
Name:PATEL, TEJAL (OD)
Entity Type:Individual
Prefix:
First Name:TEJAL
Middle Name:
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 1:20 MYSTIC LN FL 1
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1942
Mailing Address - Country:US
Mailing Address - Phone:610-477-2830
Mailing Address - Fax:610-477-2838
Practice Address - Street 1:20 MYSTIC LN FL 1
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-1942
Practice Address - Country:US
Practice Address - Phone:610-477-2830
Practice Address - Fax:610-477-2838
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007370152W00000X
DEI3-0001395152W00000X
TX7795-TG152W00000X
WI21329-875152W00000X
PAOEG003275152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03064124Medicaid