Provider Demographics
NPI:1578588802
Name:MUGOSA, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MUGOSA
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 1:6 STEPTOE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301-2500
Mailing Address - Country:US
Mailing Address - Phone:775-289-3612
Mailing Address - Fax:775-289-6467
Practice Address - Street 1:6 STEPTOE CIRCLE
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-2500
Practice Address - Country:US
Practice Address - Phone:775-289-3612
Practice Address - Fax:775-289-6467
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086597208600000X
MO2008011481208600000X
NV12476208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2586198Medicaid
OH2586198Medicaid
A166622Medicare UPIN
OH4166622Medicare ID - Type Unspecified