Provider Demographics
NPI:1093903262
Name:MANIAM-MOHAN, MYDILI R (MD)
Entity Type:Individual
Prefix:
First Name:MYDILI
Middle Name:R
Last Name:MANIAM-MOHAN
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 1:6255 N FRESNO ST
Mailing Address - Street 2:STE 106
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5271
Mailing Address - Country:US
Mailing Address - Phone:559-435-1500
Mailing Address - Fax:559-478-5082
Practice Address - Street 1:6255 N FRESNO ST
Practice Address - Street 2:STE 106
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5271
Practice Address - Country:US
Practice Address - Phone:559-435-1500
Practice Address - Fax:559-478-5082
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54039207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics