Provider Demographics
NPI:1982606604
Name:MEHTA, PRABODH (MD)
Entity type:Individual
Prefix:DR
First Name:PRABODH
Middle Name:
Last Name:MEHTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 WOODLAND DRIVE,
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2746
Mailing Address - Country:US
Mailing Address - Phone:270-765-5921
Mailing Address - Fax:270-765-4391
Practice Address - Street 1:1324 WOODLAND DRIVE,
Practice Address - Street 2:SUITE A
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2746
Practice Address - Country:US
Practice Address - Phone:270-765-5921
Practice Address - Fax:270-765-4391
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30758207RC0000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64307580Medicaid
KYE64589Medicare UPIN
KY0200204Medicare PIN