Provider Demographics
NPI:1356484034
Name:VIRENDRAKUMAR D MEHTA MD PA
Entity Type:Organization
Organization Name:VIRENDRAKUMAR D MEHTA MD PA
Other - Org Name:VIRENDRAKUMAR D MEHTA MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRENDRAKUMAR
Authorized Official - Middle Name:D
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-766-1079
Mailing Address - Street 1:1815 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5054
Mailing Address - Country:US
Mailing Address - Phone:940-766-1079
Mailing Address - Fax:940-322-6023
Practice Address - Street 1:1815 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5054
Practice Address - Country:US
Practice Address - Phone:940-766-1079
Practice Address - Fax:940-322-6023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2432207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123332202Medicaid
TX123332202Medicaid