Healthcare Provider Details

I. General information

NPI: 1528716784
Provider Name (Legal Business Name): SEJAL MEHTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date: 03/22/2023
Reactivation Date: 03/30/2023

III. Provider practice location address

615 N MICHIGAN ST FL 5
SOUTH BEND IN
46601-1033
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-7275
  • Fax: 574-647-3696
Mailing address:
  • Phone: 574-647-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01100701A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: