Healthcare Provider Details

I. General information

NPI: 1417136029
Provider Name (Legal Business Name): MANISHA MEHTA D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST STE 1011
DETROIT MI
48201-2017
US

IV. Provider business mailing address

4160 JOHN R ST STE 1011
DETROIT MI
48201-2017
US

V. Phone/Fax

Practice location:
  • Phone: 313-833-3090
  • Fax: 313-833-7843
Mailing address:
  • Phone: 313-833-3090
  • Fax: 313-833-7843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36. 003467
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number5901002275
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: