Healthcare Provider Details

I. General information

NPI: 1073129813
Provider Name (Legal Business Name): KAJAL KIRTI PATEL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 HAMPTON POINT DR STE 3
ST AUGUSTINE FL
32092-3058
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 904-287-9137
  • Fax: 904-287-9057
Mailing address:
  • Phone: 703-847-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6801
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: