Healthcare Provider Details

I. General information

NPI: 1598056483
Provider Name (Legal Business Name): ABID CHRISTOPHER MOGANNAM M.D., M.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 SAMARITAN DR
SAN JOSE CA
95124
US

IV. Provider business mailing address

1900 CAMDEN AVE STE 101
SAN JOSE CA
95124-2944
US

V. Phone/Fax

Practice location:
  • Phone: 408-559-2011
  • Fax:
Mailing address:
  • Phone: 408-899-8272
  • Fax: 408-442-5767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA123990
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberLT15520
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA123990
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: