Provider Demographics
NPI:1669482816
Name:MOHAN, MADHAN (MD)
Entity Type:Individual
Prefix:
First Name:MADHAN
Middle Name:
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 1:850 RIVERVIEW RD
Mailing Address - Street 2:PO BOX 308
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-1430
Mailing Address - Country:US
Mailing Address - Phone:606-337-6047
Mailing Address - Fax:606-337-0925
Practice Address - Street 1:850 RIVERVIEW RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1430
Practice Address - Country:US
Practice Address - Phone:606-337-6047
Practice Address - Fax:606-337-0925
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64296676Medicaid
KY0384501Medicare PIN
F61948Medicare UPIN
KY110155218Medicare PIN