Provider Demographics
NPI:1700058195
Name:MEHROTRA, PRAVEEN (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:MEHROTRA
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 1:925 CHESTNUT ST
Mailing Address - Street 2:MEZZANINE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4216
Mailing Address - Country:US
Mailing Address - Phone:215-955-5050
Mailing Address - Fax:
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:MEZZANINE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-955-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232211390200000X
PAMD446086207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102740178Medicaid
NJ0309273Medicaid
PA244647Medicare PIN