Provider Demographics
NPI:1619007697
Name:BANGALORE PUTTAIAH, MOHAN KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:KUMAR
Last Name:BANGALORE PUTTAIAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAN
Other - Middle Name:
Other - Last Name:KUMAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8828207Q00000X
SC35196207Q00000X
MN49480207Q00000X
NMMD2019-0994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID284867OtherALTIUS HEALTH PLAN BILL #
ID0007241559OtherAETNA ID #
IDM-8828OtherIDAHO MEDICAL LICENSE #
ID000010145537OtherBLUESHIELD OF IDAHO GV #
ID000010145534OtherBLUESHIELD OF IDAHO MH #
IDCS10257OtherIDAHO CONTROLLED SUBST. #
ID0-569-979-8OtherECFMG CERTIFICATION #
ID58826OtherBLUE CROSS OF IDAHO
IDP00161243OtherRAILROAD MEDICARE BILL #
ID806780500Medicaid
ID00010145533OtherBLUESHIELD OF IDAHO GF #
ID539004052 08OtherI-94 # CLASS H1B1
ID539004052 08OtherI-94 # CLASS H1B1
ID000010145534OtherBLUESHIELD OF IDAHO MH #
IDI16558Medicare UPIN