Basic Information
| Provider Information | |||||||||
| NPI: | 1831323542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATIL | ||||||||
| FirstName: | MRUNAL | ||||||||
| MiddleName: | ABHIJIT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MENDHI | ||||||||
| OtherFirstName: | MRUNAL | ||||||||
| OtherMiddleName: | SUNIL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477120 | ||||||||
| FaxNumber: | 4077700661 | ||||||||
| Practice Location | |||||||||
| Address1: | 14075 TOWN LOOP BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328376132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074385858 | ||||||||
| FaxNumber: | 4074387172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2009 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD444385 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME123560 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 015172000 | 05 | FL | MEDICAID |