Provider Demographics
NPI:1649257916
Name:MEHTA, NIMISH (MD)
Entity type:Individual
Prefix:DR
First Name:NIMISH
Middle Name:
Last Name:MEHTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MACCORKLE AVE SE
Mailing Address - Street 2:STE 203
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1228
Mailing Address - Country:US
Mailing Address - Phone:304-388-1724
Mailing Address - Fax:304-388-1721
Practice Address - Street 1:800 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3351
Practice Address - Country:US
Practice Address - Phone:304-388-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20051208000000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001718074OtherWV BCBS
WV1057343OtherWV DWC
WV1803190000Medicaid
WV4059951Medicare PIN
WV1803190000Medicaid
WV001718074OtherWV BCBS
WV930122363Medicare PIN
WV4059953Medicare PIN