Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PP0204X | Pediatric Emergency Physician | C54039 | CA |
N | 208000000X | Pediatrician | C54039 | CA |
NPI | 1093903262 |
---|---|
Provider Name | Mydili R. Maniam-Mohan |
First Address | Fresno, CA 93710-5271 |
Second Address | Fresno, CA 93710-5271 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2007 |
Last Update Date | 24/02/2015 |