Provider Demographics
NPI:1376646893
Name:MOGADAM, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MOGADAM
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 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 1206
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304
Mailing Address - Country:US
Mailing Address - Phone:703-370-1400
Mailing Address - Fax:703-370-9742
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 1206
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-370-1400
Practice Address - Fax:703-370-9742
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101020264207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B93757Medicare UPIN
158883Medicare PIN