Provider Demographics
NPI:1902995558
Name:MEHTA, JAYESH R
Entity Type:Individual
Prefix:
First Name:JAYESH
Middle Name:R
Last Name:MEHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 OLD NYACK TPKE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2461
Mailing Address - Country:US
Mailing Address - Phone:845-627-2800
Mailing Address - Fax:845-627-7827
Practice Address - Street 1:55 OLD NYACK TPKE
Practice Address - Street 2:SUITE 503
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2461
Practice Address - Country:US
Practice Address - Phone:845-627-2800
Practice Address - Fax:845-627-7827
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200651207RP1001X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01832099Medicaid
NY01832099Medicaid
39N581Medicare ID - Type Unspecified