Basic Information
| Provider Information | |||||||||
| NPI: | 1053722470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | SURAJ | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847208 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5939 HARRY HINES BLVD | ||||||||
| Address2: | PROFESSIONAL OFFICE BUILDING 2, SUITE 700 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146451919 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 10/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 273657 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | T3163 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 110116362A | 05 | MA | MEDICAID |