Healthcare Provider Details

I. General information

NPI: 1497984447
Provider Name (Legal Business Name): DIEGO MOGUILLANSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2009
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD CONGENITAL HEART CENTER
GAINESVILLE FL
32610-0296
US

IV. Provider business mailing address

2563 SW 87TH DR SUITE 201
GAINESVILLE FL
32608-9379
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7517
  • Fax: 352-392-0547
Mailing address:
  • Phone: 215-279-1298
  • Fax: 586-279-1294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME110760
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME110760
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: