Basic Information
Provider Information | |||||||||
NPI: | 1487983540 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOGBE | ||||||||
FirstName: | BENNET | ||||||||
MiddleName: | KOKU | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MB CHB | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 N MAIN AVE | ||||||||
Address2: |   | ||||||||
City: | LOVINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 882602813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5753966611 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 99 EAST STATE STREET | ||||||||
Address2: | MAB SUITE 107 | ||||||||
City: | GLOVERSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 120780010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187735687 | ||||||||
FaxNumber: | 5187735232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2009 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 268700 | NY | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | MD445883 | PA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | MD2022-1343 | NM | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 03624577 | 05 | NY |   | MEDICAID |