Healthcare Provider Details

I. General information

NPI: 1770549099
Provider Name (Legal Business Name): RAJENDRA H MEHTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W WASHINGTON AVE STE 102
JACKSON MI
49201-2141
US

IV. Provider business mailing address

306 W WASHINGTON AVE STE 102
JACKSON MI
49201-2141
US

V. Phone/Fax

Practice location:
  • Phone: 517-435-0260
  • Fax: 517-435-0261
Mailing address:
  • Phone: 517-435-0260
  • Fax: 517-435-0261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberRM068733
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: