Provider Demographics
NPI:1700084514
Name:PATEL, MITTAL JIGNESH (MD)
Entity Type:Individual
Prefix:DR
First Name:MITTAL
Middle Name:JIGNESH
Last Name:PATEL
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:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-774-7263
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:1100 W LAKE COMMONS DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-7932
Practice Address - Country:US
Practice Address - Phone:706-250-6919
Practice Address - Fax:706-250-7232
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA64239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336413954OtherGROUP NPI
GA393541474DMedicaid
1336413954OtherGROUP NPI