MEDICARE: MANISHA MEHTA D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	36. 003467	OH
2	213EP1101X	Primary Podiatric Medicine Podiatrist	5901002275	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1891939682	OTHER	MI	DME SUPPLIER NUMBER

General Provider Information

NPI Number	:	1417136029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANISHA MEHTA D.P.M.

Provider Business Mailing Address
First Line	:	4160 JOHN R ST STE 1011
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2017
Country	:	US
Telephone Number	:	313-833-3090
Fax Number	:	313-833-7843

Provider Business Practice Location Address
First Line	:	4160 JOHN R ST STE 1011
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2017
Country	:	US
Telephone Number	:	313-833-3090
Fax Number	:	313-833-7843

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2007
Last Update Date	:	08/11/2023

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Directions to “ MANISHA MEHTA D.P.M.” Practice Location

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