Provider Demographics
NPI:1184904955
Name:MEHTA, VARUN RAJEEV
Entity type:Individual
Prefix:
First Name:VARUN
Middle Name:RAJEEV
Last Name:MEHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 CLINICAL DR # CL365
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5233
Mailing Address - Country:US
Mailing Address - Phone:317-278-5022
Mailing Address - Fax:317-274-2695
Practice Address - Street 1:541 CLINICAL DR # CL365
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5233
Practice Address - Country:US
Practice Address - Phone:317-278-5022
Practice Address - Fax:317-274-2695
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72521207R00000X
IN11017755A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR72521OtherTRAINING PERMIT
IN11017755AOtherMEDICAL RESIDENCY PERMIT