Provider Demographics
NPI:1720078173
Name:MEHTA, PRAVIN CHIMANLAL (MD)
Entity Type:Individual
Prefix:
First Name:PRAVIN
Middle Name:CHIMANLAL
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 1:230D W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4121
Mailing Address - Country:US
Mailing Address - Phone:770-229-6007
Mailing Address - Fax:770-229-1518
Practice Address - Street 1:230D W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4121
Practice Address - Country:US
Practice Address - Phone:770-229-6007
Practice Address - Fax:770-229-1518
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30028207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000316391OtherBLUE CROSS
KY64300288Medicaid
P00113101OtherTRAVELERS MEDICARE
KY9115Medicare ID - Type Unspecified
KY64300288Medicaid