Provider Demographics
NPI:1720037328
Name:MOHAN, VISHNU (MD)
Entity Type:Individual
Prefix:DR
First Name:VISHNU
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 1:15298 SW ROYALTY PKWY
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3904
Mailing Address - Country:US
Mailing Address - Phone:503-620-0721
Mailing Address - Fax:503-968-1181
Practice Address - Street 1:15298 SW ROYALTY PKWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3904
Practice Address - Country:US
Practice Address - Phone:503-620-0721
Practice Address - Fax:503-968-1181
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227407Medicaid
G63311Medicare UPIN
OR227407Medicaid