Provider Demographics
NPI:1841269164
Name:MOHAN, KOCHUNNI (MD)
Entity type:Individual
Prefix:DR
First Name:KOCHUNNI
Middle Name:
Last Name:MOHAN
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 1:714 S TRUMBULL ST
Mailing Address - Street 2:STE 2
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-4217
Mailing Address - Country:US
Mailing Address - Phone:989-892-8456
Mailing Address - Fax:898-892-4692
Practice Address - Street 1:714 S TRUMBULL ST
Practice Address - Street 2:STE 2
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-4217
Practice Address - Country:US
Practice Address - Phone:989-892-8456
Practice Address - Fax:898-892-4692
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKM037321207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0600901571OtherBCBS PROVIDER ID
MI4347665Medicaid
MI0600901571OtherBCBS PROVIDER ID
MION38590Medicare ID - Type UnspecifiedMEDICARE