Provider Demographics
NPI:1003490921
Name:MEHTA, MAITRI (DO)
Entity Type:Individual
Prefix:
First Name:MAITRI
Middle Name:
Last Name:MEHTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1038 GARDENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-3017
Mailing Address - Country:US
Mailing Address - Phone:408-636-8636
Mailing Address - Fax:
Practice Address - Street 1:102 S HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3013
Practice Address - Country:US
Practice Address - Phone:815-285-8520
Practice Address - Fax:815-285-8903
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-078487207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program