Healthcare Provider Details

I. General information

NPI: 1184124687
Provider Name (Legal Business Name): KETAN MEHTA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 N PALMER ROAD
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

10815 DEBORAH DR
POTOMAC MD
20854-2716
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberH0101709
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number7226621
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: