Provider Demographics
NPI:1548764053
Name:PATEL, JAY DIPAK (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:DIPAK
Last Name:PATEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2615
Mailing Address - Country:US
Mailing Address - Phone:770-897-7043
Mailing Address - Fax:770-996-3941
Practice Address - Street 1:11 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2615
Practice Address - Country:US
Practice Address - Phone:770-897-7043
Practice Address - Fax:770-996-3941
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA88748207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003255080AMedicaid