Provider Demographics
NPI:1629239561
Name:MOHAN, CHANDLER VIMAL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDLER
Middle Name:VIMAL
Last Name:MOHAN
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:PO BOX 1646
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-1646
Mailing Address - Country:US
Mailing Address - Phone:386-466-1106
Mailing Address - Fax:386-466-1821
Practice Address - Street 1:4812 W US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-5126
Practice Address - Country:US
Practice Address - Phone:386-466-1106
Practice Address - Fax:386-466-1821
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243179207VG0400X, 208D00000X
FLME101708207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629239561Medicaid
FL002878500Medicaid
VA1629239561Medicaid
FLEN375ZMedicare PIN