Healthcare Provider Details

I. General information

NPI: 1306955356
Provider Name (Legal Business Name): RENUKA MEHTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MCG 1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1499 WALTON WAY SUITE 1400
AUGUSTA GA
30901-2602
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4402
  • Fax: 706-721-7872
Mailing address:
  • Phone: 706-863-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number049921
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number01063017
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD.15244R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: