Basic Information
| Provider Information | |||||||||
| NPI: | 1104864008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOGTADER | ||||||||
| FirstName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 TRENTON RD | ||||||||
| Address2: | |||||||||
| City: | BROWNS MILLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080151705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098931200 | ||||||||
| FaxNumber: | 6098931213 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 TRENTON RD | ||||||||
| Address2: | |||||||||
| City: | BROWNS MILLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080151705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098931200 | ||||||||
| FaxNumber: | 6097350175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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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 | 207RC0000X | 25MA06270700 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 6754309 | 05 | NJ | MEDICAID |