Provider Demographics
NPI:1326015124
Name:MOGAN, GLEN RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:RAYMOND
Last Name:MOGAN
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 1:200 S ORANGE AVE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5817
Mailing Address - Country:US
Mailing Address - Phone:973-322-7755
Mailing Address - Fax:973-322-7764
Practice Address - Street 1:200 S ORANGE AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5817
Practice Address - Country:US
Practice Address - Phone:973-322-7755
Practice Address - Fax:973-322-7764
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA037333207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0355607Medicaid
NJ507195Medicare ID - Type Unspecified
C61297Medicare UPIN