Provider Demographics
NPI:1962495200
Name:MEHTA, MANOJ KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:KUMAR
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 1:1732 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1508
Mailing Address - Country:US
Mailing Address - Phone:847-256-1855
Mailing Address - Fax:866-375-3001
Practice Address - Street 1:1732 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1508
Practice Address - Country:US
Practice Address - Phone:847-256-1855
Practice Address - Fax:866-375-3001
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087435207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G45667Medicare UPIN
L85678Medicare PIN