Provider Demographics
NPI:1710016761
Name:MOHAN, MAMATHA G (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMATHA
Middle Name:G
Last Name:MOHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 EDGEWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:970-395-1550
Mailing Address - Fax:973-395-1556
Practice Address - Street 1:60 EVERGREEN PLACE
Practice Address - Street 2:SUITE 400
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018
Practice Address - Country:US
Practice Address - Phone:973-395-1550
Practice Address - Fax:973-395-1556
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA08172600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00059104OtherRAILROAD MEDICARE
NJ200019307OtherBLUE CROSS BLUE SHIELD
NJI73877Medicare UPIN