Healthcare Provider Details

I. General information

NPI: 1407897481
Provider Name (Legal Business Name): JAGDISH A PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 W 12TH ST
TRACY CA
95376-3437
US

IV. Provider business mailing address

644 W 12TH ST
TRACY CA
95376-3437
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-8984
  • Fax: 209-832-8988
Mailing address:
  • Phone: 209-832-8984
  • Fax: 209-832-8988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA31816
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberA31816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: