Provider Demographics
NPI:1205949724
Name:MEHTA, DIVYESH G (MD)
Entity type:Individual
Prefix:
First Name:DIVYESH
Middle Name:G
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 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:602-470-5000
Mailing Address - Fax:
Practice Address - Street 1:2525 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4948
Practice Address - Country:US
Practice Address - Phone:602-344-1015
Practice Address - Fax:602-344-1174
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30158207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ684789Medicaid
AZ684789Medicaid
H52198Medicare UPIN
IL0040149903OtherBCBS PROVIDER #