Provider Demographics
NPI:1518932839
Name:MOGOR, JOHN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:MOGOR
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:7128 FULTON ST E
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8413
Practice Address - Country:US
Practice Address - Phone:616-825-3530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063084208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3062947Medicaid
MI110110939OtherMEDICARE RAILROAD
MI0D14849OtherMEDICARE RAILROAD
MI0D14849001Medicare PIN
MI110110939OtherMEDICARE RAILROAD
MI0D14849OtherMEDICARE RAILROAD