Provider Demographics
NPI:1366493983
Name:MOHOLKAR, MANOJ (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:MOHOLKAR
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 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:228 BILLERICA RD
Practice Address - Street 2:ADULT URGENT CARE
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3604
Practice Address - Country:US
Practice Address - Phone:978-250-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA157492207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA33111Medicare ID - Type Unspecified
MAH49479Medicare UPIN