Provider Demographics
NPI:1770591604
Name:MOHAN, PONNIAH (MD)
Entity type:Individual
Prefix:MR
First Name:PONNIAH
Middle Name:
Last Name:MOHAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6255 N FRESNO ST STE 106
Mailing Address - Street 2:FIRST PEDIATRICS MEDICAL GROUP, INC
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5271
Mailing Address - Country:US
Mailing Address - Phone:559-435-1500
Mailing Address - Fax:559-478-5082
Practice Address - Street 1:6255 N FRESNO ST STE 106
Practice Address - Street 2:FIRST PEDIATRICS MEDICAL GROUP, INC
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5271
Practice Address - Country:US
Practice Address - Phone:559-435-1500
Practice Address - Fax:559-478-5082
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIPM039179208000000X
CAC54717208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3505021342OtherBCBS
MI3505021342OtherBCBS
MI1682676Medicaid