Provider Demographics
NPI:1851387278
Name:MOUGIN, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MOUGIN
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 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-214-2920
Practice Address - Fax:928-214-2925
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346652Medicaid
AZZ90345Medicare PIN
Z112340Medicare PIN
AZZ193057Medicare PIN