Provider Demographics
NPI:1992156418
Name:KRISHNAMOHAN, RAATHATHULAKSI
Entity type:Individual
Prefix:
First Name:RAATHATHULAKSI
Middle Name:
Last Name:KRISHNAMOHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MONROE ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2420
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:13667 EUREKA RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1332
Practice Address - Country:US
Practice Address - Phone:734-530-6777
Practice Address - Fax:734-681-1156
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301109859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine