Provider Demographics
NPI:1861673980
Name:MOZENA, JOHN D (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:MOZENA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8305 SE MONTEREY
Mailing Address - Street 2:STE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-7728
Mailing Address - Country:US
Mailing Address - Phone:503-652-1121
Mailing Address - Fax:503-652-2193
Practice Address - Street 1:8305 SE MONTEREY
Practice Address - Street 2:STE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-7728
Practice Address - Country:US
Practice Address - Phone:503-652-1121
Practice Address - Fax:503-652-2193
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR158213EP1101X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR146910Medicaid
ORR116773Medicare PIN
OR146910Medicaid
OR480003893Medicare PIN