Healthcare Provider Details

I. General information

NPI: 1073584868
Provider Name (Legal Business Name): RAGHUNATH MEHTA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 WAYNE LN
TAPPAN NY
10983-1117
US

IV. Provider business mailing address

40 WAYNE LN
TAPPAN NY
10983-1117
US

V. Phone/Fax

Practice location:
  • Phone: 845-365-3968
  • Fax: 845-365-3968
Mailing address:
  • Phone: 845-365-3968
  • Fax: 845-365-3968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number105948
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number105948
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number105948
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: