1578555876 NPI number — DR. DANA JUNE HOGAN MD

Table of content: (NPI 1396117305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578555876 NPI number — DR. DANA JUNE HOGAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOGAN
Provider First Name:
DANA
Provider Middle Name:
JUNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578555876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 CAPITAL AVE STE 105
Provider Second Line Business Mailing Address:
P O BOX 1379
Provider Business Mailing Address City Name:
WATKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30677-1832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-769-9410
Provider Business Mailing Address Fax Number:
706-769-9475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1160 CAPITAL AVE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30677-1832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-769-9410
Provider Business Practice Location Address Fax Number:
706-769-9475
Provider Enumeration Date:
08/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  044236 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000755961E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000755961G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 044236 . This is a "MEDICAL LISCENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1578555876 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1138488848 . This is a "GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 582560190 . This is a "TAX ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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