Provider Demographics
NPI:1477572022
Name:MEHTA, SANJAY S (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:S
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 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-904-7000
Practice Address - Fax:217-904-7742
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116289207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK29957Medicare PIN
ILH65967Medicare UPIN
IL6447860011Medicare NSC
H65967Medicare UPIN
ILK35892Medicare PIN
ILIL3270408Medicare PIN