Provider Demographics
NPI:1114187614
Name:MEHTA, VIVEK MUKUR (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:MUKUR
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 1:2222 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4872
Mailing Address - Country:US
Mailing Address - Phone:602-277-6211
Mailing Address - Fax:866-242-5309
Practice Address - Street 1:2222 E HIGHLAND AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4872
Practice Address - Country:US
Practice Address - Phone:602-277-6211
Practice Address - Fax:866-242-5309
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46083208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ706184Medicaid
AZ46083OtherAZ LICENSE #
AZ706184Medicaid