Healthcare Provider Details

I. General information

NPI: 1720065097
Provider Name (Legal Business Name): JITENDRA M. PATEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 E MAIN ST
PARK HILLS MO
63601-2634
US

IV. Provider business mailing address

PO BOX 506
PARK HILLS MO
63601-0506
US

V. Phone/Fax

Practice location:
  • Phone: 573-431-3341
  • Fax: 573-431-5205
Mailing address:
  • Phone: 573-431-0554
  • Fax: 573-431-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number106981
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: