Provider Demographics
NPI:1326144080
Name:MOGABGAB, EDWARD R (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:R
Last Name:MOGABGAB
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1700 ABBEY PL
Mailing Address - Street 2:STE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3734
Mailing Address - Country:US
Mailing Address - Phone:704-262-7240
Mailing Address - Fax:704-262-7249
Practice Address - Street 1:1700 ABBEY PL
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3734
Practice Address - Country:US
Practice Address - Phone:704-262-7240
Practice Address - Fax:704-262-7249
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2018-10-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC9501609207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8959904Medicaid
NC59904OtherBLUE CROSS
NCB61713Medicare UPIN
NC8959904Medicaid