Provider Demographics
NPI:1164534640
Name:VOGT, ERIC IVAN (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:IVAN
Last Name:VOGT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 W TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-0892
Mailing Address - Country:US
Mailing Address - Phone:573-636-5115
Mailing Address - Fax:
Practice Address - Street 1:3207 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-0892
Practice Address - Country:US
Practice Address - Phone:573-636-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007007793208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology