Provider Demographics
NPI:1982653127
Name:MOHAN PENMETCHA, M.D., P.A.
Entity Type:Organization
Organization Name:MOHAN PENMETCHA, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENMETCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-492-8700
Mailing Address - Street 1:4217 MARSH RIDGE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4416
Mailing Address - Country:US
Mailing Address - Phone:972-307-3456
Mailing Address - Fax:972-307-6789
Practice Address - Street 1:4217 MARSH RIDGE RD STE 110
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4416
Practice Address - Country:US
Practice Address - Phone:972-307-3456
Practice Address - Fax:972-307-6789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9779207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170889301Medicaid
TXG25104Medicare UPIN
TX00810XMedicare ID - Type Unspecified