Healthcare Provider Details

I. General information

NPI: 1063593531
Provider Name (Legal Business Name): SANTHA MOHAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 RANDALL AVE
BRONX NY
10473-3629
US

IV. Provider business mailing address

16 BYRNE LANE
HARRINGTON PARK NJ
07640-1068
US

V. Phone/Fax

Practice location:
  • Phone: 718-542-3060
  • Fax: 718-542-8165
Mailing address:
  • Phone: 212-831-3660
  • Fax: 201-784-8429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number150725
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: