Basic Information
| Provider Information | |||||||||
| NPI: | 1508126780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | VIRAL | ||||||||
| MiddleName: | MAINAK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5325 FARAON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162716406 | ||||||||
| FaxNumber: | 8162717986 | ||||||||
| Practice Location | |||||||||
| Address1: | 1255 HIGHWAY 54 W | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043673014 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 005441 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 73779 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 2015022429 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 73779 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1508126780 | 05 | MO | MEDICAID | 201124300A | 05 | KS | MEDICAID | P01584894 | 01 | MO | RR MEDICARE | OTHER |