Provider Demographics
NPI:1508196742
Name:MEHTA, AVINDER SINGH
Entity Type:Individual
Prefix:
First Name:AVINDER
Middle Name:SINGH
Last Name:MEHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 RENAISSANCE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 RENAISSANCE DR
Practice Address - Street 2:SUITE 207
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1330
Practice Address - Country:US
Practice Address - Phone:847-296-6161
Practice Address - Fax:847-296-6262
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine