Provider Demographics
NPI:1518969138
Name:MEHTA, SANJAY RASIK (DO)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:RASIK
Last Name:MEHTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 PEPPERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2091
Mailing Address - Country:US
Mailing Address - Phone:276-250-1675
Mailing Address - Fax:206-203-0141
Practice Address - Street 1:340 PEPPERS FERRY RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2091
Practice Address - Country:US
Practice Address - Phone:276-250-1675
Practice Address - Fax:206-203-0141
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV254207R00000X
VA0102202805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6000748000Medicaid
WV2028962Medicare PIN
WV6000748000Medicaid
WV2028961Medicare PIN
WV2028963Medicare PIN