Provider Demographics
NPI:1831114156
Name:PATHAK, AJAY JAYENDRA (MD)
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:JAYENDRA
Last Name:PATHAK
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 1:1780 W MCDERMOTT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3363
Mailing Address - Country:US
Mailing Address - Phone:972-954-1469
Mailing Address - Fax:469-283-2743
Practice Address - Street 1:2833 W ELDORADO PKWY STE 307
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-3540
Practice Address - Country:US
Practice Address - Phone:972-292-0300
Practice Address - Fax:972-292-0301
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6202207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115547504Medicaid
TX115547501Medicaid
TX8072J9Medicare ID - Type Unspecified
TX8A1779Medicare ID - Type Unspecified
TXF77442Medicare UPIN