Provider Demographics
NPI:1679527485
Name:MOGLOWSKY, MARK DAVID (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:MOGLOWSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2324
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35201-2324
Mailing Address - Country:US
Mailing Address - Phone:256-533-7064
Mailing Address - Fax:256-704-0115
Practice Address - Street 1:119 LONGWOOD DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4522
Practice Address - Country:US
Practice Address - Phone:256-533-6488
Practice Address - Fax:256-533-6495
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA032157207RG0100X
FLME99163207RG0100X
WI31469207RG0100X
ALMD.31660207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL139181Medicaid
IAE48344Medicare UPIN
AL102I109176Medicare PIN