Healthcare Provider Details

I. General information

NPI: 1871843615
Provider Name (Legal Business Name): VIRAJ PATEL PA -C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 LAKEVIEW AVE
SOUTH PLAINFIELD NJ
07080
US

IV. Provider business mailing address

1075 CENTRAL AVE
CLARK NJ
07066-1116
US

V. Phone/Fax

Practice location:
  • Phone: 908-941-2227
  • Fax:
Mailing address:
  • Phone: 732-574-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MP00294100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00294100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: