Provider Demographics
NPI:1942409453
Name:PATIL MEHTA, SMITA (MD)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:
Last Name:PATIL 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 1:2510 W DUNLAP AVE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2737
Mailing Address - Country:US
Mailing Address - Phone:602-789-0344
Mailing Address - Fax:602-789-8279
Practice Address - Street 1:2510 W DUNLAP AVE
Practice Address - Street 2:SUITE 290
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2737
Practice Address - Country:US
Practice Address - Phone:602-789-0344
Practice Address - Fax:602-789-8279
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36118593208M00000X, 207R00000X
AZ44077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ606665Medicaid
IL213411Medicare PIN