Basic Information
| Provider Information | |||||||||
| NPI: | 1528000890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUDAN | ||||||||
| FirstName: | PUSHPA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RANGANATHAN | ||||||||
| OtherFirstName: | PUSHPAVALLI | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 45 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038217788 | ||||||||
| FaxNumber: | 6038215620 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038217788 | ||||||||
| FaxNumber: | 6038215620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 10/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 48483 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 14664 | NH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110006287/A | 05 | MA | MEDICAID | 7051466 | 01 | NH | CIGNA | OTHER | 1528000890 | 01 | NH | ANTHEM BCBS NH | OTHER | 30209531 | 05 | NH | MEDICAID | P00892397 | 01 | NH | RAILROAD MEDICARE | OTHER |