Provider Demographics
NPI:1154909430
Name:MEHTA, SAMIR (DO)
Entity type:Individual
Prefix:
First Name:SAMIR
Middle Name:
Last Name:MEHTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 COLONIA BLVD
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-2831
Mailing Address - Country:US
Mailing Address - Phone:848-203-7097
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:848-203-7097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program