Provider Demographics
NPI:1871811141
Name:BOGAN, KRISTI AMANDA (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:AMANDA
Last Name:BOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTI
Other - Middle Name:
Other - Last Name:OATIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1100 SOUTH BLVD
Mailing Address - Street 2:APT 322
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-7001
Mailing Address - Country:US
Mailing Address - Phone:469-617-1106
Mailing Address - Fax:
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-4243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1416822085R0202X
KYTP1072085P0229X, 2085R0204X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYTP107OtherKENTUCKY MEDICAL LICENSE