Provider Demographics
NPI:1659539799
Name:PATEL, MAYANK HARISH
Entity Type:Individual
Prefix:
First Name:MAYANK
Middle Name:HARISH
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:703-396-5292
Mailing Address - Fax:703-396-5297
Practice Address - Street 1:8700 SUDLEY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4418
Practice Address - Country:US
Practice Address - Phone:703-396-5292
Practice Address - Fax:703-396-5297
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659539799Medicaid
VAVAA104459Medicare PIN