Provider Demographics
NPI:1043325350
Name:HOGAN, REBECCA JO (OD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:JO
Last Name:HOGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 BERLIN MALL RD
Mailing Address - Street 2:UNIT 4
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-8292
Mailing Address - Country:US
Mailing Address - Phone:802-223-2090
Mailing Address - Fax:802-223-5336
Practice Address - Street 1:282 BERLIN MALL RD
Practice Address - Street 2:UNIT 4
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-8292
Practice Address - Country:US
Practice Address - Phone:802-223-2090
Practice Address - Fax:802-223-5336
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000301152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008111Medicaid
VT1008111Medicaid
VTU90232Medicare UPIN