Basic Information
| Provider Information | |||||||||
| NPI: | 1275893281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | PRAVIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147446589 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 E LAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | ST FRANCIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532356053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147446589 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2012 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 036.123715 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 8485 | SD | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 23054 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7208720 | 05 | SD | MEDICAID |