Provider Demographics
NPI:1487646295
Name:MOHAN, PONNAIAH C (MD)
Entity Type:Individual
Prefix:DR
First Name:PONNAIAH
Middle Name:C
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:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:SHANNON
Mailing Address - State:AL
Mailing Address - Zip Code:35142-0092
Mailing Address - Country:US
Mailing Address - Phone:888-212-4243
Mailing Address - Fax:888-878-5157
Practice Address - Street 1:3125 MATLOCK RD STE 107
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2905
Practice Address - Country:US
Practice Address - Phone:817-899-8109
Practice Address - Fax:888-878-5157
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1245207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8226BOOtherBLUE CROSS
TX173763701Medicaid
TXP00262936OtherRR MEDICARE
TX173763701Medicaid
TX8D5966Medicare PIN