Provider Demographics
NPI:1528000890
Name:MUDAN, PUSHPA R (MD)
Entity Type:Individual
Prefix:MS
First Name:PUSHPA
Middle Name:R
Last Name:MUDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:PUSHPAVALLI
Other - Middle Name:D
Other - Last Name:RANGANATHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3312
Mailing Address - Country:US
Mailing Address - Phone:603-821-7788
Mailing Address - Fax:603-821-5620
Practice Address - Street 1:45 HIGH ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3312
Practice Address - Country:US
Practice Address - Phone:603-821-7788
Practice Address - Fax:603-821-5620
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48483207P00000X
NH14664207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110006287/AMedicaid
NH7051466OtherCIGNA
NH1528000890OtherANTHEM BCBS NH
NH30209531Medicaid
NHP00892397OtherRAILROAD MEDICARE
NH30209531Medicaid
MA110006287/AMedicaid