Provider Demographics
NPI:1407952229
Name:MOHAN, AYYAMPALAYAM RAJU
Entity Type:Individual
Prefix:DR
First Name:AYYAMPALAYAM
Middle Name:RAJU
Last Name:MOHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:AYYAMPALAYAM
Other - Middle Name:RAJU
Other - Last Name:MOHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1818 N ORANGE GROVE AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3028
Mailing Address - Country:US
Mailing Address - Phone:909-622-6050
Mailing Address - Fax:909-620-4632
Practice Address - Street 1:1818 N ORANGE GROVE AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3028
Practice Address - Country:US
Practice Address - Phone:909-622-6050
Practice Address - Fax:909-620-4632
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37819208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A378190Medicaid
CA00A378190Medicaid