Basic Information
| Provider Information | |||||||||
| NPI: | 1104836618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGUE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 N TUSTIN AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143471000 | ||||||||
| FaxNumber: | 7146471245 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 FROST ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589393400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 12/30/2015 | ||||||||
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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 | 207L00000X | A64470 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A644700 | 05 | CA | MEDICAID |