Healthcare Provider Details

I. General information

NPI: 1235351610
Provider Name (Legal Business Name): PRADEEP S MOHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12315 JUDSON RD STE 110
LIVE OAK TX
78233-3263
US

IV. Provider business mailing address

12315 JUDSON RD STE 110
LIVE OAK TX
78233-3263
US

V. Phone/Fax

Practice location:
  • Phone: 325-665-9111
  • Fax:
Mailing address:
  • Phone: 210-566-8332
  • Fax: 210-682-9151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036116392
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License NumberN8956
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number036116392
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberN8956
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: