Healthcare Provider Details

I. General information

NPI: 1669528915
Provider Name (Legal Business Name): OWEN MOGABGAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 MARYLAND DR
LULING LA
70070
US

IV. Provider business mailing address

2730 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-5939
US

V. Phone/Fax

Practice location:
  • Phone: 985-308-1604
  • Fax: 985-308-1605
Mailing address:
  • Phone: 337-369-9213
  • Fax: 337-367-9624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number228777
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberBP1-0038347
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD.206730
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: