Provider Demographics
NPI:1114921806
Name:MOHAN, GOWDHAMI (MD)
Entity type:Individual
Prefix:
First Name:GOWDHAMI
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 1:785 OHIO AVE STE 3E
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6215
Mailing Address - Country:US
Mailing Address - Phone:662-351-0702
Mailing Address - Fax:662-351-0703
Practice Address - Street 1:785 OHIO AVE STE 3E
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6215
Practice Address - Country:US
Practice Address - Phone:662-351-0702
Practice Address - Fax:662-351-0703
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17935207R00000X, 207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8607OtherMEDICARE GROUP NUMBER
SCT20901Medicaid
SCP00944908OtherRR MEDICARE
GA050001919CMedicaid
MS200011416Medicaid
GA050001919CMedicaid
SC7111Medicare PIN