Provider Demographics
NPI:1699728584
Name:MEHRA, MUKTESHWAR (MD)
Entity type:Individual
Prefix:
First Name:MUKTESHWAR
Middle Name:
Last Name:MEHRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:L
Other - Last Name:MEHRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0500
Mailing Address - Country:US
Mailing Address - Phone:217-698-9722
Mailing Address - Fax:217-391-0392
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-9722
Practice Address - Fax:217-391-0392
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360464192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL330617OtherPERSONAL CARE
ILCD7143OtherPGA RR MEDICARE GROUP#
IL036046419Medicaid
IL08421024OtherBC/BS PGA
IL262941OtherHEALTHLINK
IL6394POtherCATERPILLAR PGA
ILP00453807OtherRR MED ID
IL020057300OtherBLACK LUNG PGA
IL14D0949277OtherCLIA PGA
IL036046419OtherIL STATE LICENSE
IL133586700OtherACS-OWCP PGA GROUP#
ILCD7143OtherPGA RR MEDICARE GROUP#