Healthcare Provider Details

I. General information

NPI: 1336262146
Provider Name (Legal Business Name): KETUL RAMAN PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 S CLYDE MORRIS BLVD STE 100
PORT ORANGE FL
32129-2300
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 386-788-1242
  • Fax: 386-756-8802
Mailing address:
  • Phone: 904-398-3385
  • Fax: 904-265-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME112375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: