Basic Information
| Provider Information | |||||||||
| NPI: | 1134116585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | TEJAL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8309 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616152170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096939540 | ||||||||
| FaxNumber: | 3096939542 | ||||||||
| Practice Location | |||||||||
| Address1: | 7715 N GRAND PRAIRIE DR | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096911320 | ||||||||
| FaxNumber: | 3096911344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046009810 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046009810 | 05 | IL | MEDICAID | P00261601 | 01 | IL | MEDICARE RAILROAD | OTHER | 046009810 | 01 | IL | ILLINOIS DPA LICENSE | OTHER |