Healthcare Provider Details

I. General information

NPI: 1336113752
Provider Name (Legal Business Name): MARK JEFFREY MOGUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 W MILLER ST
ORLANDO FL
32806-2032
US

IV. Provider business mailing address

92 W MILLER ST
ORLANDO FL
32806-2032
US

V. Phone/Fax

Practice location:
  • Phone: 218-418-5883
  • Fax: 321-841-8560
Mailing address:
  • Phone: 218-418-5883
  • Fax: 321-841-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG068539
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberME121139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: