Provider Demographics
NPI:1265457832
Name:MOGOL, GJEROME DE GUZMAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:GJEROME
Middle Name:DE GUZMAN
Last Name:MOGOL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 RENAISSANCE POINTE
Mailing Address - Street 2:#303
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3506
Mailing Address - Country:US
Mailing Address - Phone:407-296-4067
Mailing Address - Fax:
Practice Address - Street 1:555 MARTIN ST
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-3544
Practice Address - Country:US
Practice Address - Phone:407-905-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 11522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer