Provider Demographics
NPI:1134123987
Name:BOGGS, LOUIS E (OD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:E
Last Name:BOGGS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 W HOUGHTON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-9451
Mailing Address - Country:US
Mailing Address - Phone:989-366-7525
Mailing Address - Fax:989-366-5405
Practice Address - Street 1:888 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9451
Practice Address - Country:US
Practice Address - Phone:989-366-7525
Practice Address - Fax:989-366-5405
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI2953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1562533Medicaid
MI099G21001OtherBLUE CROSS BLUE SHIELD
MI0G26503Medicare PIN
MI0159320001Medicare NSC
MIT33542Medicare UPIN
MICG6506Medicare PIN