Healthcare Provider Details

I. General information

NPI: 1982606604
Provider Name (Legal Business Name): PRABODH MEHTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 WOODLAND DRIVE, SUITE A
ELIZABETHTOWN KY
42701-2746
US

IV. Provider business mailing address

1324 WOODLAND DRIVE, SUITE A
ELIZABETHTOWN KY
42701-2746
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-5921
  • Fax: 270-765-4391
Mailing address:
  • Phone: 270-765-5921
  • Fax: 270-765-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number30758
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: