Provider Demographics
NPI:1962591834
Name:MEHTA, KHUSAL D
Entity type:Individual
Prefix:
First Name:KHUSAL
Middle Name:D
Last Name:MEHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KHUSALDAS
Other - Middle Name:D
Other - Last Name:MEHTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:430 N VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DINUBA
Mailing Address - State:CA
Mailing Address - Zip Code:93618-1631
Mailing Address - Country:US
Mailing Address - Phone:559-591-1060
Mailing Address - Fax:559-591-1083
Practice Address - Street 1:430 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618-1631
Practice Address - Country:US
Practice Address - Phone:559-591-1060
Practice Address - Fax:559-591-1083
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A36047208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA360470Medicaid
CARHM53912FOtherRURAL HEALTH CLINIC NUMBE
CA553912OtherMEDICARE IDENTIFICATION NUMBER
CA553912OtherMEDICARE IDENTIFICATION NUMBER