Provider Demographics
NPI:1063593531
Name:MOHAN, SANTHA (MD)
Entity type:Individual
Prefix:DR
First Name:SANTHA
Middle Name:
Last Name:MOHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BYRNE LANE
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07640-1068
Mailing Address - Country:US
Mailing Address - Phone:212-831-3660
Mailing Address - Fax:201-784-8429
Practice Address - Street 1:1790 RANDALL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-3629
Practice Address - Country:US
Practice Address - Phone:718-542-3060
Practice Address - Fax:718-542-8165
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00715320Medicaid
NYB80149Medicare UPIN
NY00715320Medicaid