Provider Demographics
NPI:1780881821
Name:MEHL, ELENA MARIE (MD)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:MARIE
Last Name:MEHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-2048
Mailing Address - Country:US
Mailing Address - Phone:248-437-1744
Mailing Address - Fax:
Practice Address - Street 1:210 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-2048
Practice Address - Country:US
Practice Address - Phone:248-437-1744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105259207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8160OtherCHIROPRACTIC LICENSE
TX0020661-01Medicaid
TXCO6092019 MCDOtherOLD MEDICAID NUMBER
TXU73315Medicare UPIN
TX609201Medicare ID - Type Unspecified