Basic Information
| Provider Information | |||||||||
| NPI: | 1144214925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | RAJESH | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 CHADWICK DR | ||||||||
| Address2: | STE 105 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392043465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013762982 | ||||||||
| FaxNumber: | 6013762981 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013522273 | ||||||||
| FaxNumber: | 6017143415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 13294 | MS | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00121687 | 05 | MS | MEDICAID |