Provider Demographics
NPI:1407417181
Name:PATEL, KOMAL J (RD)
Entity Type:Individual
Prefix:
First Name:KOMAL
Middle Name:J
Last Name:PATEL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 HUNTERS LAKE CT
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1010
Mailing Address - Country:US
Mailing Address - Phone:484-905-2280
Mailing Address - Fax:
Practice Address - Street 1:147 HUNTERS LAKE CT
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-1010
Practice Address - Country:US
Practice Address - Phone:484-905-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006047133V00000X
MO2022035854133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered