Provider Demographics
NPI:1225084643
Name:MOHAN, SUDEEP (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDEEP
Middle Name:
Last Name:MOHAN
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 1:1015 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-2556
Mailing Address - Country:US
Mailing Address - Phone:989-754-3000
Mailing Address - Fax:989-755-1365
Practice Address - Street 1:315 E WARWICK DR
Practice Address - Street 2:SUITE E
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1083
Practice Address - Country:US
Practice Address - Phone:989-466-2877
Practice Address - Fax:989-466-5116
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061678207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4943524Medicaid
MIG54088Medicare UPIN
MI4943524Medicaid