Provider Demographics
NPI:1467423624
Name:GURUBHAGAVATULA, MOHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:
Last Name:GURUBHAGAVATULA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E CITY AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1710
Mailing Address - Country:US
Mailing Address - Phone:610-664-8200
Mailing Address - Fax:866-267-4029
Practice Address - Street 1:301 E CITY AVE STE 235
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1710
Practice Address - Country:US
Practice Address - Phone:610-664-8200
Practice Address - Fax:866-267-4029
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012602207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGU1507200OtherPIN NUMBER
PAGU1507200OtherPIN NUMBER
PA165062Medicare ID - Type UnspecifiedGROUP PROV ID