Basic Information
| Provider Information | |||||||||
| NPI: | 1235100462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGAR | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 161581 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787161581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123635779 | ||||||||
| FaxNumber: | 5122924458 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 W BEN WHITE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787048095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127304800 | ||||||||
| FaxNumber: | 8889750945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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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 | 208100000X | L3246 | TX | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 150774101 | 05 | TX | MEDICAID |