Healthcare Provider Details

I. General information

NPI: 1942385174
Provider Name (Legal Business Name): DONALD CHARLES MOHS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL STE 4460
SOUTH BEND IN
46601-1168
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-235-1010
  • Fax:
Mailing address:
  • Phone: 574-647-1840
  • Fax: 574-237-9383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301510868
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01060186A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: