Provider Demographics
NPI:1720115504
Name:PATEL, JIGNESH BABU (OD)
Entity Type:Individual
Prefix:DR
First Name:JIGNESH
Middle Name:BABU
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 1:2834 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2136
Mailing Address - Country:US
Mailing Address - Phone:215-934-6472
Mailing Address - Fax:
Practice Address - Street 1:9171 ROOSEVELT BLVD STE I
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2218
Practice Address - Country:US
Practice Address - Phone:215-673-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000911152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAV04634Medicare UPIN