Provider Demographics
NPI:1528036852
Name:MOHAN, SMITA KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:KRISHNA
Last Name:MOHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SMITA
Other - Middle Name:MADHAV
Other - Last Name:PURANDARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:27303 SLEEPY HOLLOW AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4203
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:
Practice Address - Street 1:27303 SLEEPY HOLLOW AVENUE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-4203
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-11
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94700207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200065050AMedicaid
OK24R531915Medicare ID - Type Unspecified
OK200065050AMedicaid