1770784936 NPI number — DAVID A BOGAN OD PC

Table of content: (NPI 1770784936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770784936 NPI number — DAVID A BOGAN OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID A BOGAN OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BOGAN EYECARE CENTER
Provider Other Organization Name Type Code:
3
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:
1770784936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
480 E. NORTHFIELD DRIVE
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
BROWNSBURG
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46112-2435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-852-4751
Provider Business Mailing Address Fax Number:
317-852-4671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 E. NORTHFIELD DRIVE
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
BROWNSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46112-2435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-852-4751
Provider Business Practice Location Address Fax Number:
317-852-4671
Provider Enumeration Date:
05/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOGAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-852-4751

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18002028A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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