Provider Demographics
NPI:1992293849
Name:MEHTA, KETAN
Entity type:Individual
Prefix:
First Name:KETAN
Middle Name:
Last Name:MEHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N MCMULLEN BOOTH RD STE A2-2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2100
Mailing Address - Country:US
Mailing Address - Phone:727-725-2719
Mailing Address - Fax:
Practice Address - Street 1:1700 N MCMULLEN BOOTH RD STE A2-2
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2100
Practice Address - Country:US
Practice Address - Phone:727-725-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4149213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery