Provider Demographics
NPI:1881793917
Name:MOHAN, KRISHNA M (MD)
Entity type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:M
Last Name:MOHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KRISHNA
Other - Middle Name:M
Other - Last Name:MOHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDPC
Mailing Address - Street 1:4700 BROADWAY APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-1549
Mailing Address - Country:US
Mailing Address - Phone:212-567-2222
Mailing Address - Fax:212-567-2345
Practice Address - Street 1:4700 BROADWAY APT 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-1549
Practice Address - Country:US
Practice Address - Phone:212-567-2222
Practice Address - Fax:212-567-2345
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126596208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY126596OtherLICENSE
NY#00374034Medicaid
NY22-2851771OtherTAX ID-M.D.P.C
#06A291Medicare ID - Type Unspecified
NY126596OtherLICENSE