Provider Demographics
NPI:1790775955
Name:MEHROTRA, VISHNU (MD)
Entity Type:Individual
Prefix:
First Name:VISHNU
Middle Name:
Last Name:MEHROTRA
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:PO BOX 1264
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-8764
Mailing Address - Country:US
Mailing Address - Phone:518-786-1296
Mailing Address - Fax:518-786-1293
Practice Address - Street 1:1300 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1628
Practice Address - Country:US
Practice Address - Phone:518-262-5422
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129891207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F56672Medicare UPIN