Healthcare Provider Details

I. General information

NPI: 1780693341
Provider Name (Legal Business Name): PRATIMA M MEHTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5825 BROADWAY SUITE A
MERRILLVILLE IN
46410-2687
US

IV. Provider business mailing address

441,SCARBOROUGH ROAD,
VALPARAISO IN
46385-8008
US

V. Phone/Fax

Practice location:
  • Phone: 219-884-1400
  • Fax: 219-884-1453
Mailing address:
  • Phone: 219-465-1834
  • Fax: 219-548-7061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number01032516A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01032516A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: