Provider Demographics
NPI:1760418677
Name:MOGEL, GREG TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:TODD
Last Name:MOGEL
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-8541
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO493602085R0202X
CAA863782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47333316Medicaid
CA00G863780Medicaid
CA00G863780G56OtherCAL-OPTIMA
CA300139027OtherRAIL ROAD MEDICARE
CA00G863780OtherBLUE SHIELD PROVIDER
CO021222OtherKAISER COMMERCIAL NUMBER
CO47333316Medicaid
CA00G863780G56OtherCAL-OPTIMA
CAWG86378DMedicare PIN
CAWG86378GMedicare PIN
CA00G863780Medicaid
COP01077974Medicare PIN
CAWG86378EMedicare PIN
CAH79480Medicare UPIN
CAWG86378AMedicare PIN
COCOAAA3341Medicare PIN