Provider Demographics
NPI:1336113752
Name:MOGUL, MARK JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:MOGUL
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 1:11913 KEATING DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2531
Mailing Address - Country:US
Mailing Address - Phone:813-295-5105
Mailing Address - Fax:
Practice Address - Street 1:2550 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:813-295-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1211392080P0207X, 2080P0207X
CAG068539208000000X
FL1211392080P0207X
NC2003008502080P0207X
WI1012522080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891344XMedicaid
NCF48508Medicare UPIN
NC891344XMedicaid