Healthcare Provider Details

I. General information

NPI: 1205561859
Provider Name (Legal Business Name): DR. JOHN MOGANNAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROADWAY STE 2700
SACRAMENTO CA
95820-1536
US

IV. Provider business mailing address

378 EMBARCADERO W UNIT 419
OAKLAND CA
94607-4534
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-9913
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A22102
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number20A22102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: