Provider Demographics
NPI:1033295324
Name:MOHAN, PETAIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:PETAIAH
Middle Name:
Last Name:MOHAN
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 1:1710 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3357
Mailing Address - Country:US
Mailing Address - Phone:304-255-6051
Mailing Address - Fax:304-255-6051
Practice Address - Street 1:194 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2804
Practice Address - Country:US
Practice Address - Phone:304-255-6051
Practice Address - Fax:304-255-6051
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV184002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0110044000Medicaid