Provider Demographics
NPI:1194704106
Name:MOHAN, VENKATACHALA (MD)
Entity type:Individual
Prefix:
First Name:VENKATACHALA
Middle Name:
Last Name:MOHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 116TH AVE NE
Mailing Address - Street 2:#560
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:425-454-4768
Mailing Address - Fax:425-462-8021
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:#560
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-454-4768
Practice Address - Fax:425-462-8021
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT50607207RG0100X
WA37468207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8248411Medicaid
WA141895OtherLABOR & INDUSTRIES
G38996Medicare UPIN
WA141895OtherLABOR & INDUSTRIES