Provider Demographics
NPI:1578567319
Name:MOGEN, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:MOGEN
Suffix:
Gender:M
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:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-225-0378
Mailing Address - Fax:605-225-7919
Practice Address - Street 1:105 S STATE ST
Practice Address - Street 2:SUITE 113
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4500
Practice Address - Country:US
Practice Address - Phone:605-225-0378
Practice Address - Fax:605-225-7919
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD1379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5603473Medicaid
SD5603474Medicaid
ND1379Medicaid
S3013Medicare PIN
SD5603473Medicaid
SDS103393Medicare PIN