Provider Demographics
NPI:1417566084
Name:MOHTA, AVANI SUSHILKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:AVANI
Middle Name:SUSHILKUMAR
Last Name:MOHTA
Suffix:
Gender:F
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:CARLE FOUNDATION HOSPITAL, 611 W. PARK STREET
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:217-383-4633
Mailing Address - Fax:217-326-1300
Practice Address - Street 1:CARLE FOUNDATION HOSPITAL, 611 W. PARK STREET
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-383-4633
Practice Address - Fax:217-326-1300
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.077206207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine