Provider Demographics
NPI:1508919945
Name:MOGK, NEAL W (MD)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:W
Last Name:MOGK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1818
Practice Address - Country:US
Practice Address - Phone:928-913-8800
Practice Address - Fax:928-913-8801
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2021-10-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ17321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ277477Medicaid
AZAZ0848210OtherBCBS
AZAZ0848210OtherBCBS
C99998Medicare UPIN