Provider Demographics
NPI:1104021062
Name:PRABU, MOHAN (MD)
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:
Last Name:PRABU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAN PRABU
Other - Middle Name:
Other - Last Name:AYYASWAMY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2354 W BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2354 W BOULEVARD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6069
Practice Address - Country:US
Practice Address - Phone:765-457-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072686A2084N0400X
NE278852084N0400X
FLME1497322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology