Provider Demographics
NPI:1972176832
Name:MOGILI, PADMAVATHI
Entity Type:Individual
Prefix:
First Name:PADMAVATHI
Middle Name:
Last Name:MOGILI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11213 LEE HWY STE H
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5698
Mailing Address - Country:US
Mailing Address - Phone:703-372-4449
Mailing Address - Fax:
Practice Address - Street 1:11213 LEE HWY STE H
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5698
Practice Address - Country:US
Practice Address - Phone:703-372-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14774363A00000X, 207RE0101X
VA0110-008764363A00000X
VAC09071363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty