Healthcare Provider Details

I. General information

NPI: 1295717528
Provider Name (Legal Business Name): DOUGLAS J MOGLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

1223 GATEWAY DR
MELBOURNE FL
32901-2607
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1771
  • Fax: 321-434-1775
Mailing address:
  • Phone: 321-434-1771
  • Fax: 321-434-1775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME45551
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: