Provider Demographics
NPI:1659766590
Name:PATEL, MITAL
Entity Type:Individual
Prefix:
First Name:MITAL
Middle Name:
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 1:575 PROFESSIONAL DR STE 150
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3347
Mailing Address - Country:US
Mailing Address - Phone:678-312-5200
Mailing Address - Fax:
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3333
Practice Address - Country:US
Practice Address - Phone:678-312-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86221207L00000X, 208VP0014X, 207LP2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program