Provider Demographics
NPI:1114960309
Name:MEHTA, SATISH R (MD)
Entity Type:Individual
Prefix:DR
First Name:SATISH
Middle Name:R
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 1:3681 ACORN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5793
Mailing Address - Country:US
Mailing Address - Phone:313-868-7700
Mailing Address - Fax:586-776-5132
Practice Address - Street 1:21501 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3213
Practice Address - Country:US
Practice Address - Phone:586-776-4185
Practice Address - Fax:586-776-4185
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065258208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4546847 TYPE 10Medicaid
MI4700179Medicaid
MISM065258OtherBC/BS
MI4700179Medicaid
MISM065258OtherBC/BS
MIM60650243Medicare ID - Type Unspecified