Provider Demographics
NPI:1841371788
Name:MEHTA, PRANAV C (MD)
Entity type:Individual
Prefix:DR
First Name:PRANAV
Middle Name:C
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 1:2540 SHORE BLVD
Mailing Address - Street 2:APT 7A
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3941
Mailing Address - Country:US
Mailing Address - Phone:718-545-6876
Mailing Address - Fax:
Practice Address - Street 1:600 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3802
Practice Address - Country:US
Practice Address - Phone:516-823-8804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234180207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01807294Medicaid
NY31N711Medicare ID - Type Unspecified
NY01807294Medicaid