Provider Demographics
NPI:1093936668
Name:CAMPBELL-MOGG, SHIRLEY (MD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:CAMPBELL-MOGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 NW 4TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2850
Mailing Address - Country:US
Mailing Address - Phone:954-791-5420
Mailing Address - Fax:954-791-5950
Practice Address - Street 1:4101 NW 4TH STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2839
Practice Address - Country:US
Practice Address - Phone:954-791-5420
Practice Address - Fax:954-791-5950
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68933208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378403700Medicaid