Basic Information
| Provider Information | |||||||||
| NPI: | 1093770927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGNER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 E ROBINSON RD | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | WEST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165641111 | ||||||||
| FaxNumber: | 7165641128 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 YOUNGS RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166367979 | ||||||||
| FaxNumber: | 7166367993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 192000 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01412371 | 05 | NY | MEDICAID |