Provider Demographics
NPI:1114056413
Name:MADANMOHAN, GAYATRI (MD)
Entity Type:Individual
Prefix:
First Name:GAYATRI
Middle Name:
Last Name:MADANMOHAN
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 1:970 E WASHINGTON ST
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3332
Mailing Address - Country:US
Mailing Address - Phone:330-723-0277
Mailing Address - Fax:330-723-5679
Practice Address - Street 1:1000 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2170
Practice Address - Country:US
Practice Address - Phone:330-725-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078710207ZP0105X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2217318Medicaid
OHH31074Medicare UPIN
OHMA4057251Medicare ID - Type Unspecified