Provider Demographics
NPI:1477998896
Name:PALLA, MOHAN BABU (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:BABU
Last Name:PALLA
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 1:2040 ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1837
Mailing Address - Country:US
Mailing Address - Phone:310-426-4415
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:UHC-2E
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-745-4052
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD90794207R00000X, 207RC0000X
MDPENDING207RI0011X
390200000X
MDD9074207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program