Provider Demographics
NPI:1285615120
Name:PATEL, MITUL R (MD)
Entity type:Individual
Prefix:
First Name:MITUL
Middle Name:R
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:
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Mailing Address - Street 1:250 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:SUITES # 7
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4800
Mailing Address - Country:US
Mailing Address - Phone:631-289-0900
Mailing Address - Fax:631-569-4909
Practice Address - Street 1:250 PATCHOGUE YAPHANK RD
Practice Address - Street 2:SUITES # 7
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4800
Practice Address - Country:US
Practice Address - Phone:631-289-0900
Practice Address - Fax:631-569-4909
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203391208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY67712OtherVYTRA HEALTH ID NO.
NY004AF3OtherEMPIRE BLUE CROSS ID
NY2046588OtherAETNA PROVIDER NUMBER
NYP452012OtherOXFORD HEALTH ID NO.
NYP00214307OtherRR MEDICARE ID NO.
NY01849976Medicaid
NY018499760Medicaid
NY100693OtherHIP HEALTH PLAN ID NO.
NYG62056Medicare UPIN
NYG62056Medicare UPIN
NY9610131OtherGHI PROVIDER ID