Provider Demographics
NPI:1124080049
Name:MEHANDRU, PREM LATA (MD)
Entity type:Individual
Prefix:DR
First Name:PREM
Middle Name:LATA
Last Name:MEHANDRU
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 1:120 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6328
Mailing Address - Country:US
Mailing Address - Phone:910-353-0581
Mailing Address - Fax:910-353-1536
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4830
Practice Address - Fax:513-636-7868
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV300062080N0001X
FLME1249232080N0001X
OH35-0585872080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0894028Medicaid
OH71422OtherQUALCHOICE
OH000000027600OtherANTHEM
OH3980958OtherUNITED HEALTHCARE
OHME7209281Medicare PIN
OH71422OtherQUALCHOICE