Provider Demographics
NPI:1134233588
Name:SATHYAMOORTHY, MOHANAKRISHNAN (MD)
Entity type:Individual
Prefix:DR
First Name:MOHANAKRISHNAN
Middle Name:
Last Name:SATHYAMOORTHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAN
Other - Middle Name:
Other - Last Name:SATHYAMOORTHY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-423-8585
Mailing Address - Fax:817-423-8458
Practice Address - Street 1:1121 5TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4386
Practice Address - Country:US
Practice Address - Phone:817-423-8585
Practice Address - Fax:817-423-8458
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2777207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201204904Medicaid
TX201204901Medicaid
TX8L9840Medicare PIN