Provider Demographics
NPI:1760479802
Name:MEHTA, KALA R (MD)
Entity Type:Individual
Prefix:
First Name:KALA
Middle Name:R
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74018-0368
Mailing Address - Country:US
Mailing Address - Phone:918-343-2728
Mailing Address - Fax:918-343-0783
Practice Address - Street 1:1501 N FLORENCE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3179
Practice Address - Country:US
Practice Address - Phone:918-343-2728
Practice Address - Fax:918-343-0783
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18536207RC0000X
ARE3856207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100051980AMedicaid
AR150903001Medicaid
AR150903001Medicaid
OKOK404895Medicare PIN
AR5M702Medicare ID - Type Unspecified