Provider Demographics
NPI:1194781443
Name:PATEL, MANGESH B (MD)
Entity type:Individual
Prefix:
First Name:MANGESH
Middle Name:B
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 S 78TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-4750
Mailing Address - Country:US
Mailing Address - Phone:813-740-0646
Mailing Address - Fax:813-849-0894
Practice Address - Street 1:1030 S 78TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-4750
Practice Address - Country:US
Practice Address - Phone:813-740-0646
Practice Address - Fax:813-849-0894
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371106400Medicaid
A54892Medicare UPIN
FL371106400Medicaid