Provider Demographics
NPI:1861654667
Name:SRIDARAN, MOHAN (DO)
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:
Last Name:SRIDARAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 BROAD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4010
Mailing Address - Country:US
Mailing Address - Phone:803-896-1521
Mailing Address - Fax:
Practice Address - Street 1:4344 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-4010
Practice Address - Country:US
Practice Address - Phone:803-896-1521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDO11852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry