Provider Demographics
NPI:1366101701
Name:MOGWOM, DIEUDONNE
Entity type:Individual
Prefix:MR
First Name:DIEUDONNE
Middle Name:
Last Name:MOGWOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 OCEAN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6831
Mailing Address - Country:US
Mailing Address - Phone:929-289-4904
Mailing Address - Fax:
Practice Address - Street 1:506 OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6831
Practice Address - Country:US
Practice Address - Phone:929-289-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No133N00000XDietary & Nutritional Service ProvidersNutritionist