Provider Demographics
NPI:1043289051
Name:BOGAN, DAVID L (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:BOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:150 LOWER WESTFIELD RD
Mailing Address - Street 2:STE1
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040
Mailing Address - Country:US
Mailing Address - Phone:413-536-2393
Mailing Address - Fax:413-536-1087
Practice Address - Street 1:150 LOWER WESTFIELD RD
Practice Address - Street 2:STE1
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2890
Practice Address - Country:US
Practice Address - Phone:413-536-2393
Practice Address - Fax:413-536-1087
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-02-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA57315208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3017079Medicaid
MAJ06504Medicare PIN
MA3017079Medicaid