Provider Demographics
NPI:1821192253
Name:PATEL, JITENDRA I (MD)
Entity Type:Individual
Prefix:
First Name:JITENDRA
Middle Name:I
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 1:330 N WABASH AVE
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:330 N WABASH
Practice Address - Street 2:STE 450
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2781
Practice Address - Country:US
Practice Address - Phone:765-660-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038195A207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000959990OtherANTHEM
IN100124410Medicaid