Provider Demographics
NPI:1366559486
Name:A.S.LALITH MOHAN M.D. PROF. INC
Entity type:Organization
Organization Name:A.S.LALITH MOHAN M.D. PROF. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAMANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LALITH MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-762-5078
Mailing Address - Street 1:108 LYNCH CREEK WAY
Mailing Address - Street 2:#3
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-762-5078
Mailing Address - Fax:707-763-7030
Practice Address - Street 1:108 LYNCH CREEK WAY
Practice Address - Street 2:#3
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-762-5078
Practice Address - Fax:707-763-7030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32849207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFS937AMedicare PIN
CAC03913Medicare UPIN