Provider Demographics
NPI:1154952075
Name:MOGOLLON, ORLANDO (SA-C)
Entity type:Individual
Prefix:
First Name:ORLANDO
Middle Name:
Last Name:MOGOLLON
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 WILLIAMSTOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-2738
Mailing Address - Country:US
Mailing Address - Phone:407-535-0055
Mailing Address - Fax:
Practice Address - Street 1:4560 WILLIAMSTOWN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-2738
Practice Address - Country:US
Practice Address - Phone:407-535-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16-461246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant