Healthcare Provider Details

I. General information

NPI: 1629239561
Provider Name (Legal Business Name): CHANDLER VIMAL MOHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 W US HIGHWAY 90
LAKE CITY FL
32055-5126
US

IV. Provider business mailing address

PO BOX 1646
LAKE CITY FL
32056-1646
US

V. Phone/Fax

Practice location:
  • Phone: 386-466-1106
  • Fax: 386-466-1821
Mailing address:
  • Phone: 386-466-1106
  • Fax: 386-466-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number0101243179
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101243179
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME101708
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberME101708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: