Provider Demographics
NPI:1356509004
Name:GADAM, MOHAN RAVINDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:RAVINDRA
Last Name:GADAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7500 RIALTO BLVD STE 1-140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8534
Mailing Address - Country:US
Mailing Address - Phone:512-730-3056
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:801 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4112
Practice Address - Country:US
Practice Address - Phone:512-730-3056
Practice Address - Fax:888-730-1925
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0384207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285711205Medicaid
TX285711205Medicaid
TX309946YNBVMedicare PIN