Provider Demographics
NPI:1093800070
Name:BOGARDUS, JOHN I (COTA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOGARDUS
Suffix:I
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1771
Mailing Address - Country:US
Mailing Address - Phone:518-525-1372
Mailing Address - Fax:518-525-1120
Practice Address - Street 1:310 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1771
Practice Address - Country:US
Practice Address - Phone:518-525-1372
Practice Address - Fax:518-525-1120
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004356-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant