Healthcare Provider Details

I. General information

NPI: 1497384457
Provider Name (Legal Business Name): MOHAN MUVVALA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8232 LOUISIANA BLVD NE STE A
ALBUQUERQUE NM
87113-2429
US

IV. Provider business mailing address

8206 LOUISIANA BLVD NE STE A
ALBUQUERQUE NM
87113-1738
US

V. Phone/Fax

Practice location:
  • Phone: 505-605-3286
  • Fax: 505-439-7139
Mailing address:
  • Phone: 505-605-3286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2023-1034
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58.031299
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: