Provider Demographics
NPI:1932197308
Name:PATEL, JETAL M (OD)
Entity type:Individual
Prefix:DR
First Name:JETAL
Middle Name:M
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2610 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8436
Mailing Address - Country:US
Mailing Address - Phone:480-892-8400
Mailing Address - Fax:602-212-1846
Practice Address - Street 1:10615 W THUNDERBIRD BLVD
Practice Address - Street 2:BLDG. A100
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3033
Practice Address - Country:US
Practice Address - Phone:623-977-9600
Practice Address - Fax:623-977-9602
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105171Medicare ID - Type UnspecifiedMEDICARE/MEDICAID NUMBER
AZ105170Medicare ID - Type UnspecifiedMEDICARE/MEDICAID NUMBER
AZ113608Medicare PIN
AZU86764Medicare UPIN