Basic Information
Provider Information | |||||||||
NPI: | 1902899537 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOGAN | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 161 RIVERSIDE DR | ||||||||
Address2: | SUITE M08 | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 139054176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077237454 | ||||||||
FaxNumber: | 6077231567 | ||||||||
Practice Location | |||||||||
Address1: | 161 RIVERSIDE DR | ||||||||
Address2: | SUITE M08 | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 139054176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077237454 | ||||||||
FaxNumber: | 6077231567 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2005 | ||||||||
LastUpdateDate: | 08/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 0024301 | NY | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 00415623 | 05 | NY |   | MEDICAID |