Provider Demographics
NPI:1427019934
Name:MEHTA, AJAY (MD)
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:
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 1:34659 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1346
Mailing Address - Country:US
Mailing Address - Phone:847-676-0091
Mailing Address - Fax:847-676-2374
Practice Address - Street 1:934 CENTER ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2125
Practice Address - Country:US
Practice Address - Phone:847-429-8998
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL94696Medicare ID - Type Unspecified
ILF34578Medicare UPIN