Healthcare Provider Details

I. General information

NPI: 1114056413
Provider Name (Legal Business Name): GAYATRI MADANMOHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2007
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E WASHINGTON ST
MEDINA OH
44256-2170
US

IV. Provider business mailing address

970 E WASHINGTON ST SUITE 2E
MEDINA OH
44256-3332
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-1000
  • Fax:
Mailing address:
  • Phone: 330-723-0277
  • Fax: 330-723-5679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number35078710
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35078710
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: