Provider Demographics
NPI:1073514022
Name:MOHAN, KAMAL JIT (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMAL
Middle Name:JIT
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:PO BOX 172327
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-2327
Mailing Address - Country:US
Mailing Address - Phone:901-767-1100
Mailing Address - Fax:901-761-9703
Practice Address - Street 1:6025 WALNUT GROVE ROAD
Practice Address - Street 2:SUIT NO 311
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-767-1100
Practice Address - Fax:901-761-9703
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35101207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3873573Medicaid
TNG17910Medicare UPIN
3873577Medicare PIN