Provider Demographics
NPI:1457467383
Name:MEHTA, SUDHA G (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:G
Last Name:MEHTA
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 1:220 TOTTEN POND RD
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-7500
Mailing Address - Country:US
Mailing Address - Phone:781-891-8800
Mailing Address - Fax:781-891-8830
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:#309
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-891-8800
Practice Address - Fax:781-899-7234
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41807207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2065754Medicaid
MAB32114Medicare ID - Type Unspecified
MA2065754Medicaid