Provider Demographics
NPI:1982867602
Name:MEHTA, KRUNAL J (MD)
Entity Type:Individual
Prefix:
First Name:KRUNAL
Middle Name:J
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 1:130 W ROUTE 66
Mailing Address - Street 2:SUITE 214
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6249
Mailing Address - Country:US
Mailing Address - Phone:626-335-4129
Mailing Address - Fax:
Practice Address - Street 1:130 W ROUTE 66
Practice Address - Street 2:SUITE 214
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6249
Practice Address - Country:US
Practice Address - Phone:626-335-4129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.012884207Q00000X
CAA110016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine