Healthcare Provider Details

I. General information

NPI: 1619264959
Provider Name (Legal Business Name): ANILA MEHTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 W RED BANK AVE
WOODBURY NJ
08096-1694
US

IV. Provider business mailing address

4511 RHETT LN
FAIRFAX VA
22030-6140
US

V. Phone/Fax

Practice location:
  • Phone: 856-853-2055
  • Fax: 856-848-2879
Mailing address:
  • Phone: 585-314-0557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101255550
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101255550
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: