Provider Demographics
NPI:1093091225
Name:THANIKACHALAM, MOHAN (MD,)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:
Last Name:THANIKACHALAM
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 1:311 NORTH DREXEL AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209
Mailing Address - Country:US
Mailing Address - Phone:614-440-7421
Mailing Address - Fax:
Practice Address - Street 1:311 N DREXEL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-1430
Practice Address - Country:US
Practice Address - Phone:614-440-7421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79108208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)