Healthcare Provider Details

I. General information

NPI: 1649257916
Provider Name (Legal Business Name): NIMISH MEHTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PENNSYLVANIA AVE
CHARLESTON WV
25302-3351
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE STE 203
CHARLESTON WV
25304-1228
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2550
  • Fax:
Mailing address:
  • Phone: 304-388-1724
  • Fax: 304-388-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20051
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20051
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: