Provider Demographics
NPI:1508822990
Name:MOHANTY, SANTOSH KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SANTOSH
Middle Name:KUMAR
Last Name:MOHANTY
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 1:17822 BEACH BLVD
Mailing Address - Street 2:SUITE 263
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-7101
Mailing Address - Country:US
Mailing Address - Phone:714-847-8113
Mailing Address - Fax:714-842-2497
Practice Address - Street 1:17822 BEACH BLVD
Practice Address - Street 2:SUITE 263
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7101
Practice Address - Country:US
Practice Address - Phone:714-847-8113
Practice Address - Fax:714-842-2497
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC37357174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C373570Medicaid
CAC37357OtherLICENSE
C37357AMedicare ID - Type Unspecified
A36586Medicare UPIN