Provider Demographics
NPI:1306955356
Name:MEHTA, RENUKA (MD)
Entity type:Individual
Prefix:DR
First Name:RENUKA
Middle Name:
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 1:1499 WALTON WAY
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-863-0055
Mailing Address - Fax:
Practice Address - Street 1:MCG 1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4402
Practice Address - Fax:706-721-7872
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0499212080P0203X
IN010630172080P0203X
LAMD.15244R2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG49921Medicaid
GA000927121BMedicaid
G63877Medicare UPIN