Provider Demographics
NPI:1972542736
Name:MOHAN, CHANDRA M (MD)
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:M
Last Name:MOHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AVVERAHALLI
Other - Middle Name:M
Other - Last Name:CHANDRA MOHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:141 N VINE ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201
Practice Address - Country:US
Practice Address - Phone:570-454-2467
Practice Address - Fax:570-455-2070
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030327E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011229010001Medicaid
PA50005161OtherCAPITAL BLUE CROSS
PA001122901-0003Medicaid
080335OtherFIRST PRIORITY HEALTH
PAP00092581OtherRAILROAD MEDICARE
PAP00092581OtherRAILROAD MEDICARE