Provider Demographics
NPI:1114980760
Name:MEHTA, DHARMESH S (MD)
Entity Type:Individual
Prefix:
First Name:DHARMESH
Middle Name:S
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:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-0209
Mailing Address - Country:US
Mailing Address - Phone:626-608-7320
Mailing Address - Fax:626-608-7322
Practice Address - Street 1:236 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1902
Practice Address - Country:US
Practice Address - Phone:626-608-7320
Practice Address - Fax:626-608-7322
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116929207LP2900X
CAC52522207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC52522OtherMEDICAL LICENSE
CAC52522OtherMEDICAL LICENSE
I01201Medicare UPIN
ILK30504Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ILI01201Medicare UPIN
IL10120LMedicare UPIN