Basic Information
| Provider Information | |||||||||
| NPI: | 1336140896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGARD | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6680 POE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454142854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372808400 | ||||||||
| FaxNumber: | 9372808373 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 MIAMI VALLEY DR STE 500 | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374250003 | ||||||||
| FaxNumber: | 9372456308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50-00-0768 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 50-000768 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.