Provider Demographics
NPI:1184632341
Name:BOGUE, STEPHEN C (DPM)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:BOGUE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6661 ODANA ROAD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719
Mailing Address - Country:US
Mailing Address - Phone:608-829-2535
Mailing Address - Fax:608-829-1319
Practice Address - Street 1:6661 ODANA ROAD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719
Practice Address - Country:US
Practice Address - Phone:608-829-2535
Practice Address - Fax:608-829-1319
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI730213EP1101X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43221700Medicaid
WI43221700Medicaid
WI85097Medicare ID - Type UnspecifiedGROUP
U62165Medicare UPIN