Provider Demographics
NPI:1467527762
Name:MEHTA, PRANAV RAGHUVIR (MD)
Entity Type:Individual
Prefix:DR
First Name:PRANAV
Middle Name:RAGHUVIR
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 1:12047 4TH ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2735
Mailing Address - Country:US
Mailing Address - Phone:909-797-5101
Mailing Address - Fax:909-797-5103
Practice Address - Street 1:12047 4TH ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2735
Practice Address - Country:US
Practice Address - Phone:909-797-5101
Practice Address - Fax:909-797-5103
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG078698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA07869800GMedicaid
CA07869800GMedicaid
CAG11062Medicare UPIN