Healthcare Provider Details

I. General information

NPI: 1255687950
Provider Name (Legal Business Name): KEYUR KAMLESH MEHTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 SUDLEY RD
MANASSAS VA
20110-8321
US

IV. Provider business mailing address

8609 SUDLEY RD STE 203
MANASSAS VA
20110-4500
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5000
  • Fax:
Mailing address:
  • Phone: 571-612-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101266293
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number0101266293
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: