1073514022 NPI number — DR. KAMAL JIT MOHAN MD

Table of content: DR. KAMAL JIT MOHAN MD (NPI 1073514022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073514022 NPI number — DR. KAMAL JIT MOHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOHAN
Provider First Name:
KAMAL
Provider Middle Name:
JIT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073514022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 172327
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38187-2327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-767-1100
Provider Business Mailing Address Fax Number:
901-761-9703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6025 WALNUT GROVE ROAD
Provider Second Line Business Practice Location Address:
SUIT NO 311
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-767-1100
Provider Business Practice Location Address Fax Number:
901-761-9703
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35101 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3873573 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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