Provider Demographics
NPI:1104134048
Name:PRIYA MOHANTY MEDICAL PRACTICE PLLC
Entity type:Organization
Organization Name:PRIYA MOHANTY MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRIYA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOHANTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-238-1782
Mailing Address - Street 1:2626 W STATE ST
Mailing Address - Street 2:STE # 208
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1858
Mailing Address - Country:US
Mailing Address - Phone:716-790-8038
Mailing Address - Fax:716-790-8041
Practice Address - Street 1:2626 W STATE ST
Practice Address - Street 2:STE # 208
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1858
Practice Address - Country:US
Practice Address - Phone:716-790-8038
Practice Address - Fax:716-790-8041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224111207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02319928Medicaid
PA1021088750001Medicaid
1194712695OtherINDIVIDUAL NPI
H 50828Medicare UPIN
NY02319928Medicaid