=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194704106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VENKATACHALA MOHAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2006
-----------------------------------------------------
Last Update Date | 02/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1135 116TH AVE NE #560
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-454-4768
-----------------------------------------------------
Fax | 425-462-8021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1135 116TH AVE NE #560
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-454-4768
-----------------------------------------------------
Fax | 425-462-8021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 50607
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 37468
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------