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General NPI Number Information
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NPI Number | 1326015124
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Entity Type | Individual
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Provider Name | GLEN RAYMOND MOGAN MD
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Gender | Male
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Dates
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Enumeration Date | 03/01/2006
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Last Update Date | 04/05/2017
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Provider Practice Location Address
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Address Line | 200 S ORANGE AVE SUITE 128
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City | LIVINGSTON
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State | NJ
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Zip | 07039-5817
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Country | US
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Telephone | 973-322-7755
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Fax | 973-322-7764
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Provider Business Mailing Address
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Address Line | 200 S ORANGE AVE SUITE 128
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City | LIVINGSTON
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State | NJ
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Zip | 07039-5817
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Country | US
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Telephone | 973-322-7755
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Fax | 973-322-7764
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 25MA037333
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License Number State | NJ
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