Healthcare Provider Details

I. General information

NPI: 1508132002
Provider Name (Legal Business Name): RONAK MEHTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 WAUNONA WAY
MADISON WI
53713-1710
US

IV. Provider business mailing address

1620 WAUNONA WAY
MADISON WI
53713-1710
US

V. Phone/Fax

Practice location:
  • Phone: 608-839-3104
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71546
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: