1619007697 NPI number — MOHAN KUMAR BANGALORE PUTTAIAH MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619007697 NPI number — MOHAN KUMAR BANGALORE PUTTAIAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANGALORE PUTTAIAH
Provider First Name:
MOHAN
Provider Middle Name:
KUMAR
Provider Name Prefix Text:
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:
KUMAR
Provider Other First Name:
MOHAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619007697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 N MAIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88260-2830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-396-6611
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88260-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-396-6611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2007

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: 207Q00000X , with the licence number:  M-8828 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 35196 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 49480 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD2019-0994 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 284867 . This is a "ALTIUS HEALTH PLAN BILL #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0007241559 . This is a "AETNA ID #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: M-8828 . This is a "IDAHO MEDICAL LICENSE #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010145537 . This is a "BLUESHIELD OF IDAHO GV #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010145534 . This is a "BLUESHIELD OF IDAHO MH #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: CS10257 . This is a "IDAHO CONTROLLED SUBST. #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0-569-979-8 . This is a "ECFMG CERTIFICATION #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 58826 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00161243 . This is a "RAILROAD MEDICARE BILL #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806780500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00010145533 . This is a "BLUESHIELD OF IDAHO GF #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 539004052 08 . This is a "I-94 # CLASS H1B1" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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