MEDICARE: DR. TEJAL S PATEL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046009810	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00261601	OTHER	IL	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	046009810	OTHER	IL	ILLINOIS DPA LICENSE

General Provider Information

NPI Number	:	1134116585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TEJAL S PATEL O.D.

Provider Business Mailing Address
First Line	:	8309 N KNOXVILLE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615-2170
Country	:	US
Telephone Number	:	309-693-9540
Fax Number	:	309-693-9542

Provider Business Practice Location Address
First Line	:	7715 N GRAND PRAIRIE DR
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615-9243
Country	:	US
Telephone Number	:	309-691-1320
Fax Number	:	309-691-1344

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	01/10/2014

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