Provider Demographics
NPI:1356590293
Name:MEHTA, RENA (MD)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:MEHTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 S FRENCH AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3374
Mailing Address - Country:US
Mailing Address - Phone:321-257-0489
Mailing Address - Fax:321-257-0491
Practice Address - Street 1:1506 S FRENCH AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-3374
Practice Address - Country:US
Practice Address - Phone:321-257-0489
Practice Address - Fax:321-257-0491
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121282207R00000X
IL036124383207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213921004Medicare PIN
IL211056004Medicare PIN
ILP01084723Medicare PIN