Provider Demographics
NPI:1578514667
Name:PENMETCHA, MOHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:
Last Name:PENMETCHA
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 1:4217 MARSH RIDGE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4416
Mailing Address - Country:US
Mailing Address - Phone:972-307-3456
Mailing Address - Fax:972-307-6789
Practice Address - Street 1:4217 MARSH RIDGE RD STE 110
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4416
Practice Address - Country:US
Practice Address - Phone:972-307-3456
Practice Address - Fax:972-307-6789
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9779207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041774305Medicaid
TX8C9885Medicare ID - Type Unspecified