Healthcare Provider Details

I. General information

NPI: 1821241357
Provider Name (Legal Business Name): SUYOG A MOKASHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 N BROAD ST
PHILADELPHIA PA
19140-4105
US

IV. Provider business mailing address

3509 N BROAD ST
PHILADELPHIA PA
19140-4105
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-8484
  • Fax:
Mailing address:
  • Phone: 215-707-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number238257
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number63262
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD475697
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: