Healthcare Provider Details

I. General information

NPI: 1801828553
Provider Name (Legal Business Name): JYOTI PATEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SOUTHPARK BLVD STE C-300
ST AUGUSTINE FL
32086-4162
US

IV. Provider business mailing address

105 SOUTHPARK BLVD STE C300
ST AUGUSTINE FL
32086-4162
US

V. Phone/Fax

Practice location:
  • Phone: 904-808-7246
  • Fax: 904-808-7090
Mailing address:
  • Phone: 904-808-7246
  • Fax: 904-808-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME61180
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: