Provider Demographics
NPI:1245321330
Name:MEHTA, ANNU P (MD)
Entity type:Individual
Prefix:
First Name:ANNU
Middle Name:P
Last Name:MEHTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNU
Other - Middle Name:L
Other - Last Name:GULATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:342 RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3839
Mailing Address - Country:US
Mailing Address - Phone:224-610-7698
Mailing Address - Fax:224-610-7613
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-7698
Practice Address - Fax:224-610-7613
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215928207Q00000X
IL036133533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2078040Medicaid
TX8BN840OtherBCBS
TX1947517-02Medicaid
TX1947517-02Medicaid
MAA36060Medicare PIN
MA2078040Medicaid
TXP00712726Medicare PIN