Provider Demographics
NPI:1467548040
Name:MOHAN, VIJAY KRISHNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:KRISHNAN
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 1:104 E 30TH
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065
Mailing Address - Country:US
Mailing Address - Phone:806-669-3303
Mailing Address - Fax:806-669-6611
Practice Address - Street 1:104 E 30TH
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065
Practice Address - Country:US
Practice Address - Phone:806-669-3303
Practice Address - Fax:806-669-6611
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2358208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX224950OtherBCBS
TX4530275OtherAETNA
TX115014603Medicaid
TX224950OtherBCBS
TX115014603Medicaid