Provider Demographics
NPI:1871578963
Name:BOGARD, TERRENCE DALE (MD)
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:DALE
Last Name:BOGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23470207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5702569Medicaid
16425OtherBCBS
63947OtherMEDCOST
WV3810001310Medicaid
400OtherPARTNERS
NC8916425Medicaid
5060613OtherAETNA
63947OtherMEDCOST