Provider Demographics
NPI:1992751663
Name:MOHAN, ANNU (MD)
Entity type:Individual
Prefix:
First Name:ANNU
Middle Name:
Last Name:MOHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 ROSEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:MT. PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-775-3823
Mailing Address - Fax:989-773-5061
Practice Address - Street 1:2480 ROSEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-775-3823
Practice Address - Fax:989-773-5061
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1012489OtherMCLAREN HEALTH PLAN
MI0803710282OtherBCBSM
MI4652367-10Medicaid
MI01004961OtherHEALTHPLUS COMMERCIAL
MI200000005813OtherPHP COMMERCIAL
MI4647367-10Medicaid
MI4652367-10Medicaid
MI01004961OtherHEALTHPLUS COMMERCIAL
MIP13710003Medicare PIN