Provider Demographics
NPI:1669528915
Name:MOGABGAB, OWEN (MD)
Entity type:Individual
Prefix:DR
First Name:OWEN
Middle Name:
Last Name:MOGABGAB
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 1:2730 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5939
Mailing Address - Country:US
Mailing Address - Phone:337-369-9213
Mailing Address - Fax:337-367-9624
Practice Address - Street 1:107 MARYLAND DR
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070
Practice Address - Country:US
Practice Address - Phone:985-308-1604
Practice Address - Fax:985-308-1605
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228777207R00000X
TXBP1-0038347207RC0000X
LAMD.206730207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine