Basic Information
| Provider Information | |||||||||
| NPI: | 1740356088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGUS | ||||||||
| FirstName: | DEVIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9201 MONTGOMERY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871112468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052982505 | ||||||||
| FaxNumber: | 5052982985 | ||||||||
| Practice Location | |||||||||
| Address1: | 9201 MONTGOMERY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871112468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052982505 | ||||||||
| FaxNumber: | 5052982985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD2013-0041 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 92750737 | 05 | NM | MEDICAID |