Basic Information
Provider Information | |||||||||
NPI: | 1417269655 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOHAN | ||||||||
FirstName: | MAHESH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2710 SAINT FRANCIS DR | ||||||||
Address2: | STE 419 | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 50702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192725000 | ||||||||
FaxNumber: | 3192726724 | ||||||||
Practice Location | |||||||||
Address1: | 2710 SAINT FRANCIS DR STE 419 | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507025634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192725000 | ||||||||
FaxNumber: | 3192726724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2010 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036136723 | IL | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 2014036782 | MO | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 04-36621 | KS | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 2081P2900X | 036136723 | IL | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208100000X | MD-43470 | IA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 201072640A | 05 | KS |   | MEDICAID |