Provider Demographics
NPI:1548308463
Name:MADHUSUDANAN, MOHAN (MD)
Entity type:Individual
Prefix:
First Name:MOHAN
Middle Name:
Last Name:MADHUSUDANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1145
Mailing Address - Country:US
Mailing Address - Phone:716-835-2966
Mailing Address - Fax:
Practice Address - Street 1:3435 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1145
Practice Address - Country:US
Practice Address - Phone:716-835-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425581207R00000X
NY255870174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine