Provider Demographics
NPI:1588668230
Name:PATEL, JITENDRA C (MD)
Entity Type:Individual
Prefix:
First Name:JITENDRA
Middle Name:C
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2742
Mailing Address - Street 2:
Mailing Address - City:HARBOR
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0326
Mailing Address - Country:US
Mailing Address - Phone:541-412-9800
Mailing Address - Fax:541-412-9600
Practice Address - Street 1:97825 SHOPPING CENTER AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-412-9800
Practice Address - Fax:541-412-9600
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15202207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151183Medicaid
A29179Medicare UPIN
OR101099Medicare PIN