=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104288927
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DHAVAL PANKAJ PATEL DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2016
-----------------------------------------------------
Last Update Date | 10/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 N PATTERSON ST
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31602-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-433-3417
-----------------------------------------------------
Fax | 229-433-3454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3911 BETTYS PL
-----------------------------------------------------
City | HAHIRA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31632-2771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-440-9829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 83715
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------