Provider Demographics
NPI:1134169501
Name:MOGELSON, STANLEY (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:MOGELSON
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 1:660 SHOSHONE ST E
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6110
Mailing Address - Country:US
Mailing Address - Phone:208-732-3380
Mailing Address - Fax:208-732-3300
Practice Address - Street 1:660 SHOSHONE ST E
Practice Address - Street 2:SUITE 110
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6110
Practice Address - Country:US
Practice Address - Phone:208-732-3380
Practice Address - Fax:208-732-3300
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00240855OtherRR MEDICARE
IDA52481Medicare UPIN
ID11132968Medicare ID - Type UnspecifiedMEDICARE NUMBER