Provider Demographics
NPI:1770575763
Name:MEHTA, MEHUL M (MD)
Entity type:Individual
Prefix:
First Name:MEHUL
Middle Name:M
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 1:29900 LORRAINE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5266
Mailing Address - Country:US
Mailing Address - Phone:586-582-0864
Mailing Address - Fax:586-582-0964
Practice Address - Street 1:11012 E 13 MILE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2572
Practice Address - Country:US
Practice Address - Phone:586-573-6880
Practice Address - Fax:586-573-2562
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010557202086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3075874Medicaid
MIMM055720OtherBCBS PIN #
MI0E06376006Medicare PIN
F24332Medicare UPIN