Healthcare Provider Details

I. General information

NPI: 1932496619
Provider Name (Legal Business Name): JONATHAN MOGEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

IV. Provider business mailing address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-2864
  • Fax:
Mailing address:
  • Phone: 617-636-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number052280
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number269163
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: