1326048190 NPI number — DAKSHA P MEHTA MD

Table of content: DAKSHA P MEHTA MD (NPI 1326048190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326048190 NPI number — DAKSHA P MEHTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEHTA
Provider First Name:
DAKSHA
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326048190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
584 WESTPORT RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42701-2987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-769-2535
Provider Business Mailing Address Fax Number:
270-769-9020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
584 WESTPORT RD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-2987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-769-2535
Provider Business Practice Location Address Fax Number:
270-769-9020
Provider Enumeration Date:
07/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  30757 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64307572 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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