Provider Demographics
NPI:1235391640
Name:GOGNA, MUDITA (MD)
Entity Type:Individual
Prefix:DR
First Name:MUDITA
Middle Name:
Last Name:GOGNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MUDITA
Other - Middle Name:
Other - Last Name:MITTAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1111 EXPOSITION BLVD BLDG 700
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4314
Mailing Address - Country:US
Mailing Address - Phone:916-736-3399
Mailing Address - Fax:916-736-3350
Practice Address - Street 1:1528 EUREKA RD STE 102
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3047
Practice Address - Country:US
Practice Address - Phone:916-736-6644
Practice Address - Fax:916-774-0143
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2457752080P0201X, 2080P0201X, 208M00000X
CAA158169207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110088231AMedicaid
MA002106702Medicare PIN