Basic Information
| Provider Information | |||||||||
| NPI: | 1386609048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGDANOVICH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W WHITESTONE BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786132245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122503900 | ||||||||
| FaxNumber: | 5122496232 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W WHITESTONE BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786132245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122503900 | ||||||||
| FaxNumber: | 5122496232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H6779 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8405KO | 01 | TX | PTAN | OTHER |