Provider Demographics
NPI:1154311041
Name:GOGEL, JEFFREY (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:GOGEL
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 1:120 IVY LEA DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-3200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18250 FOREST RD
Practice Address - Street 2:SUITE 1
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4055
Practice Address - Country:US
Practice Address - Phone:434-385-4633
Practice Address - Fax:434-385-4714
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102036933204D00000X, 207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA282472OtherBLUE CROSS/BLUE SHIELD
VA541714597OtherTRICARE
VA541714597OtherCOMMERCIAL
VA541714597OtherCOMMERCIAL
VA120000011Medicare ID - Type Unspecified