Provider Demographics
NPI:1205195849
Name:MEHTA, BRINDA MUKESH (MD)
Entity Type:Individual
Prefix:
First Name:BRINDA
Middle Name:MUKESH
Last Name:MEHTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:530 NE GLEN OAK AVENUE
Mailing Address - Street 2:UICOMP DEPT OF PEDIATRICS, OSF NORTH BLDG. ROOM 5642
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637
Mailing Address - Country:US
Mailing Address - Phone:309-655-4746
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:UICOMP/DEPT. OF PEDIATRICS OSF NORTH BLDG. ROOM 5642
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637
Practice Address - Country:US
Practice Address - Phone:309-655-4746
Practice Address - Fax:309-655-2565
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01074184A2080P0207X
TXBP10039198390200000X
IL036.1427772080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program