Provider Demographics
NPI:1265401962
Name:MEHTA, HASUMATI VIJAYKUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:HASUMATI
Middle Name:VIJAYKUMAR
Last Name:MEHTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:HASUMATI
Other - Middle Name:VIJAYKUMAR
Other - Last Name:MEHTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 87169
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7169
Mailing Address - Country:US
Mailing Address - Phone:910-323-4091
Mailing Address - Fax:910-323-4092
Practice Address - Street 1:518 SANDHURST DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4426
Practice Address - Country:US
Practice Address - Phone:910-323-4091
Practice Address - Fax:910-323-4092
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02145OtherBCBS GROUP NUMBER
NC8958493Medicaid
NC208795OtherPTAN
NC208795OtherPTAN