Provider Demographics
NPI:1720146871
Name:MEHTA, MANISH (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:
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 1:4305 TORRANCE BLVD
Mailing Address - Street 2:109
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4409
Mailing Address - Country:US
Mailing Address - Phone:310-406-3900
Mailing Address - Fax:310-406-3902
Practice Address - Street 1:4305 TORRANCE BLVD
Practice Address - Street 2:109
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4409
Practice Address - Country:US
Practice Address - Phone:310-406-3900
Practice Address - Fax:310-406-3902
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45977208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45977Medicare ID - Type UnspecifiedID NO.