Healthcare Provider Details

I. General information

NPI: 1972092880
Provider Name (Legal Business Name): PUJA DILIP MEHTA MATHER MD,MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PUJA MEHTA MD, MS

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST
OAK LAWN IL
60453-2654
US

IV. Provider business mailing address

30 HERITAGE RD
UXBRIDGE MA
01569-1256
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-8000
  • Fax:
Mailing address:
  • Phone: 508-244-1280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA11265900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: