Healthcare Provider Details

I. General information

NPI: 1548764053
Provider Name (Legal Business Name): JAY DIPAK PATEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2615
US

IV. Provider business mailing address

11 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2615
US

V. Phone/Fax

Practice location:
  • Phone: 770-897-7043
  • Fax: 770-996-3941
Mailing address:
  • Phone: 770-897-7043
  • Fax: 770-996-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number88748
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: