Healthcare Provider Details

I. General information

NPI: 1235511924
Provider Name (Legal Business Name): MITESH PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SOTOYOME ST
SANTA ROSA CA
95405-4823
US

IV. Provider business mailing address

PO BOX 5651
ORANGE CA
92863-5651
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-4062
  • Fax: 707-525-4095
Mailing address:
  • Phone: 714-571-5000
  • Fax: 714-571-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number94-08734
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA173818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: