Provider Demographics
NPI:1083927511
Name:MEHTA, PRANEIL DAVE (MD)
Entity Type:Individual
Prefix:
First Name:PRANEIL
Middle Name:DAVE
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 1:19251 MACK AVE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2893
Mailing Address - Country:US
Mailing Address - Phone:313-343-3329
Mailing Address - Fax:
Practice Address - Street 1:19251 MACK AVE
Practice Address - Street 2:SUITE 335
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS3062508-106207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine