Healthcare Provider Details

I. General information

NPI: 1407860729
Provider Name (Legal Business Name): MARY BAILEY MEHTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 850-505-4700
  • Fax: 850-505-4772
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME61346
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: