Provider Demographics
NPI:1063463966
Name:VOGT, DAVID A (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:VOGT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56549
Mailing Address - Country:US
Mailing Address - Phone:218-483-3564
Mailing Address - Fax:
Practice Address - Street 1:1412 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:MN
Practice Address - Zip Code:56549
Practice Address - Country:US
Practice Address - Phone:218-483-3564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41351207Q00000X
MI769040207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0107997OtherMEDICA
07G62V0OtherBCBS
585241029605OtherPREFERRED ONE
MN334220400Medicaid
8HZ802Medicare ID - Type Unspecified
MN334220400Medicaid
07G62V0OtherBCBS
MN080022104Medicare PIN