Healthcare Provider Details

I. General information

NPI: 1255331419
Provider Name (Legal Business Name): PRABHU MEHTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

IV. Provider business mailing address

1000 MONTAUK HWY DEPARTMENT OF NEONATOLOGY
WEST ISLIP NY
11795-4927
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-4161
  • Fax:
Mailing address:
  • Phone: 631-376-4161
  • Fax: 631-376-3676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number171718
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: