Provider Demographics
NPI:1932496619
Name:MOGEN, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MOGEN
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 1:800 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-5000
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-972-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0522802085R0202X
390200000X
MA2691632085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program