Healthcare Provider Details

I. General information

NPI: 1104955590
Provider Name (Legal Business Name): ELBA IRIS MEHTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE
LOS ANGELES CA
90059-3019
US

IV. Provider business mailing address

24161 BENFIELD PL
DIAMOND BAR CA
91765-1865
US

V. Phone/Fax

Practice location:
  • Phone: 310-668-4641
  • Fax:
Mailing address:
  • Phone: 909-861-5605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA62030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: