=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942385174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD CHARLES MOHS JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 03/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 NAVARRE PL STE 4460
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-235-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3245 HEALTH DR STE 100
-----------------------------------------------------
City | GRANGER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46530-1380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-1840
-----------------------------------------------------
Fax | 574-237-9383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 4301510868
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 01060186A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------