Basic Information
| Provider Information | |||||||||
| NPI: | 1043289051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 LOWER WESTFIELD RD | ||||||||
| Address2: | STE1 | ||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135362393 | ||||||||
| FaxNumber: | 4135361087 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 LOWER WESTFIELD RD | ||||||||
| Address2: | STE1 | ||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010402890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135362393 | ||||||||
| FaxNumber: | 4135361087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 02/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 57315 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3017079 | 05 | MA | MEDICAID |