Healthcare Provider Details

I. General information

NPI: 1629770383
Provider Name (Legal Business Name): MOHIT MATHAVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N 11TH ST
QUINCY IL
62301-2662
US

IV. Provider business mailing address

612 N 11TH ST
QUINCY IL
62301-2662
US

V. Phone/Fax

Practice location:
  • Phone: 217-224-9484
  • Fax: 217-224-7950
Mailing address:
  • Phone: 217-224-9484
  • Fax: 217-224-7950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.089034
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number125.089034
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: