Provider Demographics
NPI:1942331608
Name:MEHTA, KETAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:C
Last Name:MEHTA
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 1:3867 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-5244
Mailing Address - Country:US
Mailing Address - Phone:707-525-3780
Mailing Address - Fax:707-525-3783
Practice Address - Street 1:3867 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-5244
Practice Address - Country:US
Practice Address - Phone:707-525-3780
Practice Address - Fax:707-525-3783
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41306174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A413060Medicaid
A29348Medicare UPIN