Provider Demographics
NPI:1477645786
Name:MOHAN, KRISHNA JATAVALLABHULA (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:JATAVALLABHULA
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 1:158 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-331-0175
Mailing Address - Fax:626-967-3849
Practice Address - Street 1:158 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:626-331-0175
Practice Address - Fax:626-967-3849
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34175207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A341750Medicaid
WA34175AMedicare ID - Type Unspecified
CA00A341750Medicaid