Provider Demographics
NPI:1063470680
Name:MEHTA, MRUGENDRA I (MD)
Entity Type:Individual
Prefix:
First Name:MRUGENDRA
Middle Name:I
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 1:2977 WESTINGHOUSE RD
Mailing Address - Street 2:UNIT C
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845
Mailing Address - Country:US
Mailing Address - Phone:607-739-2890
Mailing Address - Fax:607-739-2893
Practice Address - Street 1:2977 WESTINGHOUSE RD
Practice Address - Street 2:UNIT C
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845
Practice Address - Country:US
Practice Address - Phone:607-739-2890
Practice Address - Fax:607-739-2893
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224413208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D07180Medicare UPIN
NYDD1686Medicare ID - Type Unspecified