Provider Demographics
NPI:1497984447
Name:MOGUILLANSKY, DIEGO (MD)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:MOGUILLANSKY
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 1:2563 SW 87TH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-9379
Mailing Address - Country:US
Mailing Address - Phone:215-279-1298
Mailing Address - Fax:586-279-1294
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:CONGENITAL HEART CENTER
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0296
Practice Address - Country:US
Practice Address - Phone:352-273-7517
Practice Address - Fax:352-392-0547
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1107602080P0202X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004148000Medicaid
FLME110760OtherSTATE OF FLORIDA, DEPARTMENT OF HEALTH
FLFM386ZMedicare PIN