Basic Information
| Provider Information | |||||||||
| NPI: | 1255407631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOGAKA | ||||||||
| FirstName: | JORAM | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4967 CROOKS RD | ||||||||
| Address2: | STE 130 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480985801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489521601 | ||||||||
| FaxNumber: | 2489521614 | ||||||||
| Practice Location | |||||||||
| Address1: | 22631 GREATER MACK AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480802055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867710100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 076566 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 810666394 | 01 | MI | TAX ID | OTHER | 1108235572 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 472234510 | 05 | MI | MEDICAID | 1106314802 | 01 | MI | BLUE CARE NETWORK | OTHER |