Provider Demographics
NPI:1225042484
Name:JAN, MOHAMMAD A (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:A
Last Name:JAN
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 1:3070 PRESIDENTIAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6293
Mailing Address - Country:US
Mailing Address - Phone:937-429-2160
Mailing Address - Fax:937-426-5663
Practice Address - Street 1:819 N 1ST ST.
Practice Address - Street 2:
Practice Address - City:DENNISON
Practice Address - State:OH
Practice Address - Zip Code:44621-1003
Practice Address - Country:US
Practice Address - Phone:740-922-7480
Practice Address - Fax:740-922-7466
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-035556207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0251632Medicaid
OH0251632Medicaid
OHB77414Medicare UPIN
OH0392759Medicare PIN