MEDICARE: SUGANDHA MOHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	D009307	AZ

General Provider Information

NPI Number	:	1336520980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUGANDHA MOHAN

Provider Business Mailing Address
First Line	:	4950 E VAN BUREN ST APT 328
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85008-7050
Country	:	US
Telephone Number	:	646-264-8736
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 N 75TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-4533
Country	:	US
Telephone Number	:	623-255-3607
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2015
Last Update Date	:	07/17/2015

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Directions to “ SUGANDHA MOHAN ” Practice Location

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