Provider Demographics
NPI:1205009487
Name:DAKSHA N. MEHTA M.D.S.C.
Entity type:Organization
Organization Name:DAKSHA N. MEHTA M.D.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:DAKSHA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-695-5520
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60121-1247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 CENTER ST STE 2002
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2104
Practice Address - Country:US
Practice Address - Phone:847-695-5520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064973261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064973Medicaid
IL036064973Medicaid
ILIL3462Medicare PIN
IL782050Medicare PIN