Provider Demographics
NPI:1760007801
Name:MOSAIC MD
Entity type:Organization
Organization Name:MOSAIC MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:IVETTE
Authorized Official - Last Name:RODRIGUEZ CUADRADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-369-8282
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-0350
Mailing Address - Country:US
Mailing Address - Phone:405-369-8282
Mailing Address - Fax:425-250-8291
Practice Address - Street 1:1401 N LELIA ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-3371
Practice Address - Country:US
Practice Address - Phone:405-369-8282
Practice Address - Fax:425-250-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-15
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty