Provider Demographics
NPI:1336113752
Name:MOGUL, MARK JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:MOGUL
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 1:92 W MILLER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:857-275-5035
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:92 W MILLER ST FL 2
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:857-275-5035
Practice Address - Fax:813-287-6306
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV248172080P0207X
MT1114822080P0207X
FL1211392080P0207X
NC2003008502080P0207X
WI1012522080P0207X
FLME1211392080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891344XMedicaid
NCF48508Medicare UPIN
NC891344XMedicaid