Provider Demographics
NPI:1114013463
Name:HOGAN, PENNY SUE (MD)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:SUE
Last Name:HOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 W PARK SQ
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2667
Mailing Address - Country:US
Mailing Address - Phone:937-372-3054
Mailing Address - Fax:937-372-3084
Practice Address - Street 1:1768 W PARK SQ
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2667
Practice Address - Country:US
Practice Address - Phone:937-372-3054
Practice Address - Fax:937-372-3084
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071125H207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2150032Medicaid
OHG81673Medicare UPIN
OH0861821Medicare ID - Type Unspecified