Provider Demographics
NPI:1205015930
Name:MOGONYE, JASON ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALAN
Last Name:MOGONYE
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 1:701 EAST I-20
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018
Mailing Address - Country:US
Mailing Address - Phone:817-852-8700
Mailing Address - Fax:
Practice Address - Street 1:701 EAST I-20
Practice Address - Street 2:SUITE 101
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018
Practice Address - Country:US
Practice Address - Phone:817-852-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8189207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine