Basic Information
| Provider Information | |||||||||
| NPI: | 1588978118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEHTA | ||||||||
| FirstName: | GAURAV | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SLEEPY HOLLOW DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19709 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 124 SLEEPY HOLLOW DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197095838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024493030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2010 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125060123 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C1-0011080 | DE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.