Provider Demographics
NPI:1801279617
Name:MEHTA, MITUL VINODKUMAR (MD)
Entity type:Individual
Prefix:
First Name:MITUL
Middle Name:VINODKUMAR
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:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:2355 N WYATT DR STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2120
Practice Address - Country:US
Practice Address - Phone:520-616-4948
Practice Address - Fax:520-616-4958
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ57240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program