Provider Demographics
NPI:1093112815
Name:USHA J. MEHTA M.D., P.A.
Entity Type:Organization
Organization Name:USHA J. MEHTA M.D., P.A.
Other - Org Name:DESOTO OB-GYN CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAGDISH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-349-1000
Mailing Address - Street 1:7600 AIRWAYS BLVD STE A
Mailing Address - Street 2:P.O.BOX 749
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5138
Mailing Address - Country:US
Mailing Address - Phone:662-349-1000
Mailing Address - Fax:662-349-8805
Practice Address - Street 1:7600 AIRWAYS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5138
Practice Address - Country:US
Practice Address - Phone:662-349-1000
Practice Address - Fax:662-349-8805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017888Medicaid