Provider Demographics
NPI:1528016813
Name:MOHAN, GOMATHY (MD)
Entity Type:Individual
Prefix:MRS
First Name:GOMATHY
Middle Name:
Last Name:MOHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11903 SOUTHERN BLVD
Mailing Address - Street 2:STE 118
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-7644
Mailing Address - Country:US
Mailing Address - Phone:561-429-5898
Mailing Address - Fax:561-429-5897
Practice Address - Street 1:11903 SOUTHERN BLVD
Practice Address - Street 2:STE 118
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-7644
Practice Address - Country:US
Practice Address - Phone:561-429-5898
Practice Address - Fax:561-429-5897
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90824208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273853800Medicaid