Basic Information
| Provider Information | |||||||||
| NPI: | 1750461760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOHAN | ||||||||
| FirstName: | SANGARAPILLAI | ||||||||
| MiddleName: | CHONDRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 SAINT FRANCIS CIR | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605232559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739899868 | ||||||||
| FaxNumber: | 7739899824 | ||||||||
| Practice Location | |||||||||
| Address1: | 4755 N KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739899868 | ||||||||
| FaxNumber: | 7739899824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036057255 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036057255 | 05 | IL | MEDICAID |