Provider Demographics
NPI:1255412094
Name:PATEL, JEETENDRA B (MD)
Entity type:Individual
Prefix:DR
First Name:JEETENDRA
Middle Name:B
Last Name:PATEL
Suffix:
Gender:
Credentials:MD
Other - Prefix:DR
Other - First Name:JEETENDRA
Other - Middle Name:BHAGUBHAI
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:619 E MASON ST STE 4P57
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-525-2535
Practice Address - Street 1:619 E MASON ST STE 4P57
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1034
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN61845207RC0000X, 207RI0011X
VA0101281934207RC0000X, 207RI0011X
IL036173952207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200951260Medicaid
UT5816058-1205OtherUTAH MEDICAL LICENSE NO.
TNQ060983Medicaid
IN000000662912OtherANTHEM PROVIDER NUMBER
IN200951260Medicaid
IN000000662912OtherANTHEM PROVIDER NUMBER
IN054770HMedicare PIN
IN264430385Medicare PIN
INM400019933Medicare PIN