Basic Information
| Provider Information | |||||||||
| NPI: | 1790221760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGOSIAN | ||||||||
| FirstName: | MARGARET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2607 STERN DR E | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322332918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035580239 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6859 BELFORT OAKS PL | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322166242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003564049 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2017 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | B225-561-88-867-0 | FL | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 106E00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 247200000 | 05 | FL | MEDICAID |