Basic Information
| Provider Information | |||||||||
| NPI: | 1265798763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | SULAY | ||||||||
| MiddleName: | PANKAJ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 12TH ST NE APT 1411 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303094760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4329781665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 WOODRUFF CIRCLE WMB 1013 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046861000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2012 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | R7048 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 73778 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | R7084 | 01 | TX | TEXAS MEDICAL BOARD | OTHER | 073778 | 01 | GA | GEORGIA COMPOSITE MEDICAL BOARD | OTHER |