Provider Demographics
NPI:1417136029
Name:MEHTA, MANISHA (DPM)
Entity Type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:MEHTA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 JOHN R ST STE 1011
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2017
Mailing Address - Country:US
Mailing Address - Phone:313-833-3090
Mailing Address - Fax:313-833-7843
Practice Address - Street 1:4160 JOHN R ST STE 1011
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2017
Practice Address - Country:US
Practice Address - Phone:313-833-3090
Practice Address - Fax:313-833-7843
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36. 003467213E00000X
MI5901002275213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316191679Medicaid
MI1417136029Medicaid
MI1891939682OtherDME SUPPLIER NUMBER
OHME4223314Medicare PIN
MIMI12250001Medicare PIN
OHME4223311Medicare PIN
MI1316191679Medicaid
OHME4223313Medicare PIN
MI1417136029Medicaid
OHME4223315Medicare PIN
MIMI1225Medicare PIN
OHME4223312Medicare PIN