Provider Demographics
NPI:1043408859
Name:MEHTA, TARAL DIVYAKANT (MD)
Entity Type:Individual
Prefix:DR
First Name:TARAL
Middle Name:DIVYAKANT
Last Name:MEHTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:ATLANTICARE REGIONAL MEDICAL CENTER
Practice Address - Street 2:JIMMIE LEEDS ROAD
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240-9104
Practice Address - Country:US
Practice Address - Phone:609-652-1000
Practice Address - Fax:609-748-5988
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA061334002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0055344Medicaid
PA101225410Medicaid
MD4133072Medicaid