Healthcare Provider Details

I. General information

NPI: 1902921208
Provider Name (Legal Business Name): MUKULIKA MEHTA M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2636 TELEGRAPH AVE SUITE A
BERKELEY CA
94704-3322
US

IV. Provider business mailing address

2636 TELEGRAPH AVE SUITE A
BERKELEY CA
94704-3322
US

V. Phone/Fax

Practice location:
  • Phone: 510-841-1647
  • Fax: 510-848-4924
Mailing address:
  • Phone: 510-841-1647
  • Fax: 510-848-4924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57.011419
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA108001
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: