Provider Demographics
NPI:1891380341
Name:MEHTA, KHUSHBU (OD)
Entity Type:Individual
Prefix:
First Name:KHUSHBU
Middle Name:
Last Name:MEHTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 BROADWAY STREET
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312
Mailing Address - Country:US
Mailing Address - Phone:219-354-8910
Mailing Address - Fax:219-354-0900
Practice Address - Street 1:2323 BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312
Practice Address - Country:US
Practice Address - Phone:219-354-8910
Practice Address - Fax:219-354-0900
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004293A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist