Provider Demographics
NPI:1790205672
Name:PATEL, VIXITKUMAR (OD)
Entity type:Individual
Prefix:
First Name:VIXITKUMAR
Middle Name:
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 1:300B STERLING CT
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9026
Mailing Address - Country:US
Mailing Address - Phone:912-656-9264
Mailing Address - Fax:
Practice Address - Street 1:3264 BUFORD DR STE 100A
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-8743
Practice Address - Country:US
Practice Address - Phone:678-395-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003019152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist