Provider Demographics
NPI:1578876785
Name:MOHAN, DAVID S (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:MOHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:3534 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1361
Practice Address - Country:US
Practice Address - Phone:260-478-5130
Practice Address - Fax:260-478-5133
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01073536A207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201214460Medicaid
IN260690026Medicare PIN
IN01073536AOtherINDIANA LICENSE
IN260690026Medicare PIN