Healthcare Provider Details

I. General information

NPI: 1619105939
Provider Name (Legal Business Name): SHAUN MOHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 LEADER AVE
LEXINGTON KY
40506-9983
US

IV. Provider business mailing address

138 LEADER AVE
LEXINGTON KY
40506-9983
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-1432
  • Fax:
Mailing address:
  • Phone: 859-323-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number49591
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number35.129926
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: