Provider Demographics
NPI:1568426294
Name:MOGBO, KIRSTEN I (MD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:I
Last Name:MOGBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 W. GRAND BLVD.
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-7425
Mailing Address - Fax:313-916-7925
Practice Address - Street 1:2799 W. GRAND BLVD.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:214-645-9729
Practice Address - Fax:214-645-9289
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010592222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118182804Medicaid
TXG52872Medicare UPIN
TX8B4775Medicare ID - Type Unspecified
G52872Medicare UPIN