Provider Demographics
NPI:1336597780
Name:MOHAN, DIVYASUDHA (DO)
Entity Type:Individual
Prefix:DR
First Name:DIVYASUDHA
Middle Name:
Last Name:MOHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:DIVYA
Other - Middle Name:
Other - Last Name:MOHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:10800 KNIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-4200
Mailing Address - Country:US
Mailing Address - Phone:215-612-5161
Mailing Address - Fax:
Practice Address - Street 1:10800 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-4200
Practice Address - Country:US
Practice Address - Phone:215-612-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT017058390200000X
PAOS019595207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine