Provider Demographics
NPI:1972155505
Name:MOHANAN, SHILPA
Entity type:Individual
Prefix:
First Name:SHILPA
Middle Name:
Last Name:MOHANAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15418 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-7219
Mailing Address - Country:US
Mailing Address - Phone:501-400-3205
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7199
Practice Address - Country:US
Practice Address - Phone:501-400-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-13
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10069455390200000X
AR390200000X
GA1026832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program