Provider Demographics
NPI:1104015288
Name:GREGORY G BOGDANOVICH
Entity Type:Organization
Organization Name:GREGORY G BOGDANOVICH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOGDANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-532-3611
Mailing Address - Street 1:500 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-6014
Mailing Address - Country:US
Mailing Address - Phone:360-532-3611
Mailing Address - Fax:360-533-3286
Practice Address - Street 1:500 W MARKET ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6014
Practice Address - Country:US
Practice Address - Phone:360-532-3611
Practice Address - Fax:360-533-3286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA152W00000XWA1635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0454410001Medicare NSC