Healthcare Provider Details

I. General information

NPI: 1083301063
Provider Name (Legal Business Name): JEESHA PATEL DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 HARBOUR VIEW BLVD STE A
SUFFOLK VA
23435-2601
US

IV. Provider business mailing address

PO BOX 849795
LOS ANGELES CA
90084-9795
US

V. Phone/Fax

Practice location:
  • Phone: 757-384-6619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301502
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: