Provider Demographics
NPI:1396727426
Name:PATEL, HETAL A (OD)
Entity type:Individual
Prefix:DR
First Name:HETAL
Middle Name:A
Last Name:PATEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CODY DR
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-8780
Mailing Address - Country:US
Mailing Address - Phone:267-257-9265
Mailing Address - Fax:866-292-1094
Practice Address - Street 1:203 CODY DR
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-8780
Practice Address - Country:US
Practice Address - Phone:267-257-9265
Practice Address - Fax:866-292-1094
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00573700152W00000X
NJ27T000123400152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0069451Medicaid
NJ073603CJPMedicare ID - Type Unspecified
NJ0069451Medicaid