Provider Demographics
NPI:1780693341
Name:MEHTA, PRATIMA M (MD)
Entity type:Individual
Prefix:
First Name:PRATIMA
Middle Name:M
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 1:441,SCARBOROUGH ROAD,
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8008
Mailing Address - Country:US
Mailing Address - Phone:219-465-1834
Mailing Address - Fax:219-548-7061
Practice Address - Street 1:5825 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2687
Practice Address - Country:US
Practice Address - Phone:219-884-1400
Practice Address - Fax:219-884-1453
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032516A207Q00000X, 146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN247800COtherGROUP INDIVIDUAL
IN247800OtherGROUP
IN247800COtherGROUP INDIVIDUAL
IN703070Medicare PIN