Provider Demographics
NPI:1982932083
Name:MEHTA, MUDRESH RAJNIKANT (MD)
Entity Type:Individual
Prefix:
First Name:MUDRESH
Middle Name:RAJNIKANT
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 1:3635 VISTA AVE
Mailing Address - Street 2:14 FLOOR, DESLOGE TOWERS
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-577-8762
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:14 FLOOR, DESLOGE TOWERS
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-577-8762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013023004207R00000X
390200000X
MO2016013265207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program