Healthcare Provider Details

I. General information

NPI: 1801061957
Provider Name (Legal Business Name): PONNIAH MOHAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11446 E 13 MILE RD SUITE B
WARREN MI
48093-6571
US

IV. Provider business mailing address

11446 E 13 MILE RD SUITE B
WARREN MI
48093-6571
US

V. Phone/Fax

Practice location:
  • Phone: 586-574-2020
  • Fax: 586-574-2919
Mailing address:
  • Phone: 586-574-2020
  • Fax: 586-574-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPM039179
License Number StateMI

VIII. Authorized Official

Name: DR. PONNIAH MOHAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 586-574-2020