Provider Demographics
NPI:1093773376
Name:SHENOY, MOHAN (MD)
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:
Last Name:SHENOY
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 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:
Practice Address - Street 1:1312 W. ARCH HAVEN AVENUE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-676-4144
Practice Address - Fax:812-339-8344
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075144A207RC0000X
KS0434273207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201281210Medicaid
IN201281210Medicaid
KS1093773376OtherBCBS