Provider Demographics
NPI:1235145590
Name:HAGAN, MOWBRAY PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:MOWBRAY
Middle Name:PHILIP
Last Name:HAGAN
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 1:482 CORONA MALL
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1418
Mailing Address - Country:US
Mailing Address - Phone:951-734-6110
Mailing Address - Fax:951-734-9989
Practice Address - Street 1:482 CORONA MALL
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1418
Practice Address - Country:US
Practice Address - Phone:951-734-6110
Practice Address - Fax:951-734-9989
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A294310Medicaid
CAA25763Medicare UPIN
CA00A294310Medicaid