Healthcare Provider Details

I. General information

NPI: 1558702498
Provider Name (Legal Business Name): SIDDHANT KUMAR MEHTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 ESSEX ST STE 203
HACKENSACK NJ
07601-8566
US

IV. Provider business mailing address

660 S EUCLID AVE
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-8867
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2018011785
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA10613200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: