Provider Demographics
NPI:1407812738
Name:MEHTA, PRAVEEN S (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
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 1:4500 S LANCASTER RD
Mailing Address - Street 2:AMB CARE 11C
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7167
Mailing Address - Country:US
Mailing Address - Phone:214-857-1911
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:AMB CARE 11C
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-857-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0187178Medicaid
MAA34785Medicare ID - Type Unspecified
MAF91676Medicare UPIN