Basic Information
| Provider Information | |||||||||
| NPI: | 1982815536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOGA | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4088 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481064088 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2215 FULLER RD | ||||||||
| Address2: | VA AA HS | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
| FaxNumber: | 7342134871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101007526 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3067095 | 05 | MI | MEDICAID |