Provider Demographics
NPI:1598056483
Name:MOGANNAM, ABID CHRISTOPHER (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:ABID
Middle Name:CHRISTOPHER
Last Name:MOGANNAM
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CAMDEN AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-2944
Mailing Address - Country:US
Mailing Address - Phone:408-899-8272
Mailing Address - Fax:408-442-5767
Practice Address - Street 1:2425 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124
Practice Address - Country:US
Practice Address - Phone:408-559-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123990208600000X, 2086S0129X
NDLT155202086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery