Healthcare Provider Details

I. General information

NPI: 1790931103
Provider Name (Legal Business Name): RIYAZUDDIN S MOGALAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E DIVISION ST
FOND DU LAC WI
54935-4560
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-2020
  • Fax: 260-266-2009
Mailing address:
  • Phone: 920-926-8340
  • Fax: 920-926-8370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63783
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number63783
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: