Provider Demographics
NPI:1861460610
Name:MEHTA, SHITAL R (DO)
Entity Type:Individual
Prefix:DR
First Name:SHITAL
Middle Name:R
Last Name:MEHTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:SHITAL
Other - Middle Name:R
Other - Last Name:MEHTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:6328 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4101
Mailing Address - Country:US
Mailing Address - Phone:813-964-8526
Mailing Address - Fax:
Practice Address - Street 1:2800 WINDGUARD CIR
Practice Address - Street 2:STE 102
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-7366
Practice Address - Country:US
Practice Address - Phone:813-345-8515
Practice Address - Fax:813-345-8517
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS59391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271714000Medicaid
FL64115ZMedicare ID - Type Unspecified
FL271714000Medicaid