Provider Demographics
NPI:1154303584
Name:MEHTA, MUKUNDINI S (MD)
Entity Type:Individual
Prefix:MRS
First Name:MUKUNDINI
Middle Name:S
Last Name:MEHTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MUKUNDINI
Other - Middle Name:
Other - Last Name:MEHTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5909 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-4163
Mailing Address - Country:US
Mailing Address - Phone:708-652-2040
Mailing Address - Fax:708-652-0058
Practice Address - Street 1:5909 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-4163
Practice Address - Country:US
Practice Address - Phone:708-652-2040
Practice Address - Fax:708-652-0058
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36059220207VG0400X
IL363659220207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1411OtherCHICAGO HEALTH SERVICES (CHS) PIN
IL036059220Medicaid
IL160025319OtherRR MEDICARE PIN
IL31603182OtherBCBS
IL160025319OtherRR MEDICARE PIN
D14773Medicare UPIN