=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336113752
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK JEFFREY MOGUL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2006
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 92 W MILLER ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-418-5883
-----------------------------------------------------
Fax | 321-841-8560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 92 W MILLER ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-418-5883
-----------------------------------------------------
Fax | 321-841-8560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | G068539
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0207X
-----------------------------------------------------
Taxonomy Name | Pediatric Hematology & Oncology Physician
-----------------------------------------------------
License Number | ME121139
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------