Provider Demographics
NPI:1558490912
Name:MEHTA, KHYATI PRAVIN (MD)
Entity Type:Individual
Prefix:
First Name:KHYATI
Middle Name:PRAVIN
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 1:25845 BARTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-5300
Mailing Address - Country:US
Mailing Address - Phone:909-558-3904
Mailing Address - Fax:909-558-3906
Practice Address - Street 1:25845 BARTON RD STE 101
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-5300
Practice Address - Country:US
Practice Address - Phone:909-558-3904
Practice Address - Fax:909-558-3906
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1397652080P0206X
MEMD193472080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002883503Medicare PIN
ME002883504Medicare PIN