Healthcare Provider Details

I. General information

NPI: 1588658017
Provider Name (Legal Business Name): MUKTIRAJ MEHTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E STATE ST
CASSOPOLIS MI
49031-9339
US

IV. Provider business mailing address

960 E STATE ST
CASSOPOLIS MI
49031-9339
US

V. Phone/Fax

Practice location:
  • Phone: 269-445-2451
  • Fax: 269-445-3216
Mailing address:
  • Phone: 269-445-2451
  • Fax: 269-445-3216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301038926
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: