Provider Demographics
NPI:1558321158
Name:MOHANLAL, VIRESH (MD)
Entity Type:Individual
Prefix:
First Name:VIRESH
Middle Name:
Last Name:MOHANLAL
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 1:3885 OAKWATER CIR
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6257
Mailing Address - Country:US
Mailing Address - Phone:407-851-6226
Mailing Address - Fax:407-438-0507
Practice Address - Street 1:3885 OAKWATER CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6257
Practice Address - Country:US
Practice Address - Phone:407-894-4693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061504207R00000X
FLME109408207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004071500Medicaid
FL591561574OtherEIN
MDI11206Medicare UPIN
FF206XMedicare UPIN