Healthcare Provider Details

I. General information

NPI: 1255412094
Provider Name (Legal Business Name): JEETENDRA B PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEETENDRA BHAGUBHAI PATEL MD

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

IV. Provider business mailing address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-0706
  • Fax: 217-525-2535
Mailing address:
  • Phone: 217-788-0706
  • Fax: 217-525-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036173952
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number61845
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number61845
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101281934
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number0101281934
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036173952
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: