Provider Demographics
NPI:1235100462
Name:BOGAR, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BOGAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 161581
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78716-1581
Mailing Address - Country:US
Mailing Address - Phone:512-363-5779
Mailing Address - Fax:512-292-4458
Practice Address - Street 1:330 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-8095
Practice Address - Country:US
Practice Address - Phone:512-730-4800
Practice Address - Fax:888-975-0945
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL3246208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150774101Medicaid
TX150774101Medicaid
TX8895BOMedicare ID - Type Unspecified