Healthcare Provider Details

I. General information

NPI: 1437352556
Provider Name (Legal Business Name): UTHARA RAJU MOHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DOVER DR SUITE 2
NEWPORT BEACH CA
92663-5735
US

IV. Provider business mailing address

601 DOVER DR SUITE 2
NEWPORT BEACH CA
92663-5735
US

V. Phone/Fax

Practice location:
  • Phone: 949-646-1495
  • Fax: 949-646-2596
Mailing address:
  • Phone: 949-646-1495
  • Fax: 949-646-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA99639
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA99639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: