Healthcare Provider Details

I. General information

NPI: 1477998896
Provider Name (Legal Business Name): MOHAN BABU PALLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE STE 300
FENTON MO
63026-2387
US

IV. Provider business mailing address

2040 ROCHESTER RD
TROY MI
48083-1837
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-5065
  • Fax:
Mailing address:
  • Phone: 310-426-4415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD90794
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036160962
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD90794
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036160962
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number21166
License Number StateND
# 6
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberPENDING
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036160962
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberD9074
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2025017659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: