Provider Demographics
NPI:1821138587
Name:PATRA, AJANTA (MD)
Entity Type:Individual
Prefix:DR
First Name:AJANTA
Middle Name:
Last Name:PATRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7026 OLD KATY RD STE 276
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2187
Mailing Address - Country:US
Mailing Address - Phone:713-621-7436
Mailing Address - Fax:713-963-9051
Practice Address - Street 1:7026 OLD KATY RD STE 276
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2187
Practice Address - Country:US
Practice Address - Phone:713-621-7436
Practice Address - Fax:713-963-9051
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA089010002085R0202X
TXP20512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0274046Medicaid
NJ218329AVDMedicare UPIN
NJ0274046Medicaid