Provider Demographics
NPI:1568686806
Name:MAMBALAM, MOHAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:R
Last Name:MAMBALAM
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 1:3020 14TH ST NW
Mailing Address - Street 2:SUITE 402B
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-6865
Mailing Address - Country:US
Mailing Address - Phone:202-745-4300
Mailing Address - Fax:202-232-0723
Practice Address - Street 1:1901 D ST SE
Practice Address - Street 2:MEDICAL UNIT
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-2534
Practice Address - Country:US
Practice Address - Phone:202-673-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD20945207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine