Provider Demographics
NPI:1235351610
Name:MOHAN, PRADEEP S (MD)
Entity Type:Individual
Prefix:
First Name:PRADEEP
Middle Name:S
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 1:4200 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-1900
Mailing Address - Country:US
Mailing Address - Phone:325-665-9111
Mailing Address - Fax:
Practice Address - Street 1:4200 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CIBOLO
Practice Address - State:TX
Practice Address - Zip Code:78108-1900
Practice Address - Country:US
Practice Address - Phone:325-665-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361163922086S0122X, 2086S0105X
TXN89562086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3581444000OtherPASSPORT ADVANTAGE
IN200922110Medicaid
KY7100067840Medicaid
KY50021605OtherPASSPORT
IN200922110Medicaid