Healthcare Provider Details

I. General information

NPI: 1144752254
Provider Name (Legal Business Name): VISHAL PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1100 ROBLEY DR APT 4208
LAFAYETTE LA
70503-5528
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5582
  • Fax:
Mailing address:
  • Phone: 972-408-6256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number57553
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number26889
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: