Provider Demographics
NPI:1740613058
Name:MOGALLA, YASHASVINI (MD)
Entity Type:Individual
Prefix:
First Name:YASHASVINI
Middle Name:
Last Name:MOGALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SMOKEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-7215
Mailing Address - Country:US
Mailing Address - Phone:614-595-8373
Mailing Address - Fax:
Practice Address - Street 1:3555 OLENTANGY RIVER RD STE 1080
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3984
Practice Address - Country:US
Practice Address - Phone:614-595-8373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-11
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.128453207R00000X
PAMT203690207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0198739Medicaid