Provider Demographics
NPI:1114048667
Name:DR JOHN D MOZENA DPM PC
Entity Type:Organization
Organization Name:DR JOHN D MOZENA DPM PC
Other - Org Name:TOWN CENTER FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOZENA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-652-1121
Mailing Address - Street 1:8305 SE MONTEREY AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-7728
Mailing Address - Country:US
Mailing Address - Phone:503-652-1121
Mailing Address - Fax:503-652-2193
Practice Address - Street 1:8305 SE MONTEREY AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-7728
Practice Address - Country:US
Practice Address - Phone:503-652-1121
Practice Address - Fax:503-652-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR158213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241805Medicaid
ORDE4269Medicare PIN
OR241805Medicaid
ORR116771Medicare PIN
ORT67937Medicare UPIN