Provider Demographics
NPI:1821199001
Name:KRISHNAMOORTHY, MOHAN (MD)
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:
Last Name:KRISHNAMOORTHY
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 1:2020 GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4219
Mailing Address - Country:US
Mailing Address - Phone:858-616-8225
Mailing Address - Fax:858-616-8230
Practice Address - Street 1:2020 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4219
Practice Address - Country:US
Practice Address - Phone:858-616-8225
Practice Address - Fax:858-616-8230
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053075208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH00054Medicare UPIN
CA051515173Medicare ID - Type Unspecified