Provider Demographics
NPI:1306830203
Name:MEHTA, JYOTIR K (MD)
Entity Type:Individual
Prefix:
First Name:JYOTIR
Middle Name:K
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 1:2002 PALMYRA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1593
Mailing Address - Country:US
Mailing Address - Phone:229-312-5565
Mailing Address - Fax:229-312-5595
Practice Address - Street 1:801 13TH AVE STE A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1345
Practice Address - Country:US
Practice Address - Phone:229-436-6688
Practice Address - Fax:229-436-0307
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45887207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00797904AMedicaid
GA11BDNXTMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
GA00797904AMedicaid