Healthcare Provider Details

I. General information

NPI: 1861673980
Provider Name (Legal Business Name): JOHN D MOZENA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8305 SE MONTEREY STE 101
PORTLAND OR
97266-7728
US

IV. Provider business mailing address

8305 SE MONTEREY STE 101
PORTLAND OR
97266-7728
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-1121
  • Fax: 503-652-2193
Mailing address:
  • Phone: 503-652-1121
  • Fax: 503-652-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number158
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number158
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number158
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: