Healthcare Provider Details

I. General information

NPI: 1861912289
Provider Name (Legal Business Name): JITEN PRAKASH MEHTA D0
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 210
ORANGE CA
92868-3837
US

IV. Provider business mailing address

12665 GARDEN GROVE BLVD STE 211
GARDEN GROVE CA
92843-1916
US

V. Phone/Fax

Practice location:
  • Phone: 714-836-4204
  • Fax:
Mailing address:
  • Phone: 714-636-2890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number17684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: