Basic Information
| Provider Information | |||||||||
| NPI: | 1801828553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | JYOTI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 SOUTHPARK BLVD | ||||||||
| Address2: | STE C300 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048087246 | ||||||||
| FaxNumber: | 9048087090 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 SOUTHPARK BLVD | ||||||||
| Address2: | STE C-300 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048087246 | ||||||||
| FaxNumber: | 9048087090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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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 | 207LP2900X | ME61180 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 15162 | 01 | FL | BLUE CROSS PROVIDER NUMBE | OTHER | 34189 | 01 | FL | MEDICARE GRP NUMBER | OTHER | 05336700 | 01 | FL | AETNA PROV NUMBER | OTHER | 370492100 | 05 | FL | MEDICAID |