MEDICARE: DR. CHANDLER VIMAL MOHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	0101243179	VA
2	208D00000X	General Practice Physician	0101243179	VA
3	207VG0400X	Gynecology Physician	ME101708	FL
4	207VX0000X	Obstetrics Physician	ME101708	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629239561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHANDLER VIMAL MOHAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1646
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32056-1646
Country	:	US
Telephone Number	:	386-466-1106
Fax Number	:	386-466-1821

Provider Business Practice Location Address
First Line	:	4812 W US HIGHWAY 90
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-5126
Country	:	US
Telephone Number	:	386-466-1106
Fax Number	:	386-466-1821

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	11/04/2016

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Directions to “ DR. CHANDLER VIMAL MOHAN M.D.” Practice Location

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