Individual
MOHAN KUMAR BANGALORE PUTTAIAH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1600 N MAIN AVE, LOVINGTON, NM 88260-2830
(575) 396-6611
Mailing address
1600 N MAIN AVE, LOVINGTON, NM 88260-2830
(575) 396-6611
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
35196
SC
207Q00000X
Family Medicine Physician
49480
MN
207Q00000X
Family Medicine Physician
M-8828
ID
207Q00000X
Family Medicine Physician
Primary
MD2019-0994
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0-569-979-8
ECFMG CERTIFICATION #
ID
01
—
000010145534
BLUESHIELD OF IDAHO MH #
ID
01
—
000010145537
BLUESHIELD OF IDAHO GV #
ID
01
—
00010145533
BLUESHIELD OF IDAHO GF #
ID
01
—
0007241559
AETNA ID #
ID
01
—
284867
ALTIUS HEALTH PLAN BILL #
ID
01
—
539004052 08
I-94 # CLASS H1B1
ID
01
—
58826
BLUE CROSS OF IDAHO
ID
05
—
806780500
—
ID
01
—
CS10257
IDAHO CONTROLLED SUBST. #
ID
01
—
M-8828
IDAHO MEDICAL LICENSE #
ID
01
—
P00161243
RAILROAD MEDICARE BILL #
ID
Enumeration date
03/07/2007
Last updated
12/04/2024
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