Provider Demographics
NPI:1730215591
Name:PATEL, MONA B (OD)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:B
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11570 PANAMA CITY BEACH PKWY 100
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2502
Mailing Address - Country:US
Mailing Address - Phone:850-230-4433
Mailing Address - Fax:850-230-4434
Practice Address - Street 1:11570 PANAMA CITY BEACH PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2502
Practice Address - Country:US
Practice Address - Phone:850-230-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1532568T152W00000X
FLOPC4529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05507886Medicaid
LA1014681Medicaid
LA4R132Medicare PIN