Provider Demographics
NPI:1225551294
Name:PATEL, MITESH INDRAVADAN
Entity type:Individual
Prefix:
First Name:MITESH
Middle Name:INDRAVADAN
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WILLOW RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-2834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S BROAD ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5546
Practice Address - Country:US
Practice Address - Phone:229-228-7658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist