Provider Demographics
NPI:1942610977
Name:MEHTA, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MEHTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 KENNEDY DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4017
Mailing Address - Country:US
Mailing Address - Phone:855-295-4144
Mailing Address - Fax:631-257-5098
Practice Address - Street 1:755 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4255
Practice Address - Country:US
Practice Address - Phone:855-295-4144
Practice Address - Fax:631-257-5098
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291140207W00000X
IL036.145316207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05658911Medicaid